Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a flex-walk system for the enrollee.
You asked the Plan to pre-approve a flex-walk system. You say that you disagree with the denial. The Plan denied your request. The Plan says that the services are not medically necessary.
Our Medical director looked at the case file and the reopen request. At issue is coverage for a flex-walk system.
Our Medical Director states that while the case file contains documentation that the enrollee has progressed to the K3 functional level, the fact that the enrollee was ambulating sometimes with a 'Rollator' and sometimes with a cane is indicative of a limited K2 community ambulator (i.e. one that has the ability to traverse low level environmental barriers such as curbs, stairs or uneven surfaces). Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of a flex-walk system. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a flex-walk system have not been met. Therefore, we decided that the Plan does not have to pre-approve a flex-walk system for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for skilled nursing facility services provided on January 20, 2022.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare billing criteria are not met. Maximus overturned the Plans denial for insufficient claim information in the file. The Plan requested a reopen and provided additional information. The Plan demonstrated this claim denied because this service was billed inappropriately with an invalid Provider Tax ID. The provider submitted the claim electronically and the Tax ID billed shows to be their Secondary ID.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this case, this claim was not submitted with the appropriate Tax ID. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for skilled nursing facility services provided to the enrollee on January 20, 2022, under claim.
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for genetic testing provided to the enrollee on November 2, 2021.
You asked the Plan to pay for this testing. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria. The Plans states these services were denied on pre-authorization because the requested genetic testing (Tempus liquid biopsy next generation sequencing panel) did not meet the requirements for approval. The testing was performed despite the denial. The records show the enrollee has a diagnosis of metastatic (spread to other parts of your body) pancreatic cancer.
The Plan states this testing does not have Food & Drug Administration (FDA) approval or clearance as a companion in vitro diagnostic testing.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare has specific coverage criteria for this testing. Based on the records provided, we do not show the required Medicare criteria were met. In addition, the Plan denied this testing on pre-approval giving notice it would not be covered. Therefore, we decided that the Plan does not have to pay for genetic testing provided to the enrollee on November 2, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for transfer from one skilled nursing facility to
another.
You asked the Plan to provide coverage for the requested transfer. You say that at the time of the appeal,
continued SNF care was medically necessary due to falls and weakness. The Plan denied your request. The
Plan says Medicare coverage criteria for transfer were not met. Maximus administratively overturned the Plans
denial for a lack of notice of non-coverage in the file. The Plan requested a reopen and stated notice was not
required because this was a patient request transfer. The Plan stated you were receiving the care you needed in
the current location at the time of the appeal and that this transfer was not for services not available at the
treating facility, but because you wanted to return to a facility you were familiar with.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare only covers transfer from one
facility to another if there are services in the requested facility not available in the original facility providing
treatment. This was a request for transfer due to convenience and not due to medical necessary. In this type of
situation, the Plan is not required to provide a notice of non-coverage as you were choosing to end coverage in
one facility and transferring to another due to personal choice.
Therefore, we decided that the Plan does not have to provide coverage for transfer from one skilled nursing
facility to another.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve a medial branch block (MBB) (64493). 
 
You asked the Plan to pre-approve MBB. You say that the enrollee had 60% relief for several weeks. The Plan 
denied your request. The Plan says that the requested injection is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that after the first diagnostic facet joint procedure, there 
must be a consistent positive response of at least 80% relief of primary (index) pain. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve MBB. Our reviewer says that the 
requested MBB is medically necessary. Our physician reviewer found the provided documentation indicates 
that the enrollee had 80% pain relief for the first 24 hours after the treatment. Therefore, the reviewer found 
that the MBB is medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MBB have been met. Therefore, we decided that the Plan has to pre-approve a 
medial branch block (MBB) (64493).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on June 22, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were 
not approved in advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the services at issue in this appeal. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the lab services provided on June 22, 2022, by an out-of-network 
(OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied 
your request. The Plan says that the coverage criteria for admission to a SNF has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from May 11, 2022, to 
June 9, 2022.  
You asked the Plan to pay for the home health services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan follows Medicare rules. The rules say that information on the claim and the NOA must be correct. 
 
In this case, the start of care date billed is May 11, 2022. Claims are paid for 30-day episodes. The dates billed 
are not for a 30-day episode. As the claim was not submitted correctly, no payment can be made on this claim. 
Therefore, we decided that the Plan does not have to pay for the home health services provided from May 11, 
2022, to June 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and therapeutic exercises provided on  
July 12, 2022. 
 
You asked the Plan to pay for an office visit and therapeutic exercises. You say that you have a medical 
condition for which there is no cure. The Plan denied your request. The Plan says that the Plan covers only 
manual manipulation of the spine to correct subluxation. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for an office visit and therapeutic exercises provided on July 12, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical assistant services provided on February 1, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the code is not 
valid for assistant at surgery services. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered.  
 
In this case, you billed assistant surgery services for Current Procedural Terminology (CPT) code 14041. The 
Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that 
Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon 
this information, we find that Medicare coverage criteria for the billed services have not been met. Therefore, 
we decided that the Plan does not have to pay for the surgical assistant services provided on February 1, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you have weakness and are a high fall risk. The Plan 
denied your request. The Plan says the IRF services you are requesting do not meet the requirements for 
approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found your medical problems are stable and there are no complex nursing or rehabilitation 
needs.  While the medical record supports a need for physical or occupational therapy, there is no documented 
need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for blood test provided on May 27, 2022. 
 
You asked the Plan to waive the copayment for blood test. You say that you are disputing the share cost. The 
Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $40 
copayment for outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay $40 copayment for blood test. This item/service falls within the outpatient 
diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for blood test provided on May 27, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided on July 26, 2021 to 
August 4, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. The Plan denied your 
request. The Plan says the billed DRG is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with diagnosis code A41.9. We asked our physician 
reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was 
correct in denying the request to pay for the inpatient hospital services at the DRG originally billed. Our 
reviewer says that diagnosis code A41.9 is not supported by the records provided. Our physician reviewer 
found that the enrollee was a then, 68-year-old female who presented to the emergency department on July 26, 
2021, with weakness. The evaluation revealed stable vital signs and physical exam showed rales/rhonchi in the 
lower lung fields. Labs revealed WBC 15T, creatinine 0.72 and chest CT demonstrated bilateral patchy 
infiltrates. She was diagnosed with pneumonia and treated with IV fluids and IV antibiotics. In this case, there 
was no clinical or laboratory evidence of sepsis. The use of diagnosis code A41.9 was not supported by the 
records provided.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for the inpatient hospital services provided on July 26, 2021 to August 4, 2021, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intermittent limb compression device and related items 
provided on February 7, 2022. 
 
You asked the Plan to pay for the intermittent limb compression device and related items. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says pneumatic compression devices 
are not covered by Medicare for prevention. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
The file does not show that the enrollee has lymphedema and/ or chronic venous insufficiency with venous 
stasis ulcers. The medical records provided do not support clinical utility of the items rendered. Therefore, we 
decided that the Plan does not have to pay for the intermittent limb compression device and related items 
provided on February 7, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from April 1, 2022, to 
April 28, 2022. 
 
You asked the Plan to pay for the billed services. You say that the first 30 days of services were paid. The Plan 
denied your request. The Plan says the notice of admission was invalid. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that the notice of admission related to the final claim was not billed with a valid type of bill code. 
Based on this information, we decided that Medicare rules for coverage of the billed services have not been 
met. Therefore, we decided that the Plan does not have to pay for the home health services provided from April 
1, 2022, to April 28, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on January 3, 2022, to 
January 6, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that these 
services were reported correctly and are supported as billed. The Plan denied your request. The Plan says the 
submitted DRG for this claim is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with sepsis, unspecified organism (A41.9) and metabolic 
encephalopathy (G93.41). We asked our physician reviewer to carefully review the case file and apply the 
relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the inpatient 
hospital services at the DRG originally billed. Our reviewer says that these diagnoses are not supported in the 
medical record. Our physician reviewer found that the admitting physician described the enrollee as not toxic 
appearing; alert; with normal mood and behavior. Given the family report of worsening cognition, an 
evaluation for reversible causes was planned. The white blood cell count was 15.6K/uL with a platelet count of 
280K/uL. The hemoglobin level was 12.4g/dL with a hematocrit of 38.2%. The serum glucose level was 
155mg/dL. The serum creatinine level was 1.30mg/dL with a BUN of19mg/dL. The total bilirubin level was 
0.7mg/dL. Serum lactic acid level was 1.6mmol/L. A chest x-ray revealed persistent right basilar pleural 
effusion and mild airspace disease. Computed Tomography (CT) scan of the thorax revealed evidence of 
centrilobular emphysema, right lower lobe patchy consolidation consistent with pneumonia versus aspiration, 
and focal left lower lobe patchy ground glass opacity suggestive of atelectasis versus pneumonia. The patient 
received intravenous fluids and empiric antibiotics (Rocephin and Azithromycin) and was admitted for ongoing 
management of pneumonia and dysphagia. In this case, there was x-ray evidence of pneumonia which required 
treatment with IV antibiotics. The review has determined that the medical records supported the diagnosis of 
pneumonia, unspecified organism (J18.9). The records provided do not support the billing of the diagnoses of 
sepsis, unspecified organism (A41.9) and metabolic encephalopathy (G93.41).  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on January 3, 2022, to January 6, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro orthosis. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found current clinical guidelines designate 
robotic therapy to be of "uncertain utility compared with dose-matched conventional upper limb exercise 
therapies" with unproven benefit in the home environment. In addition, the provided records report left upper 
extremity spasticity which may be a contraindication to use of the device. The MyoPro is therefore not 
reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a MyoPro orthosis.