Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric services from January 26, 2022 onward.
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. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 the enrollee was admitted to the hospital on January 15, 2022 with Alzheimer's type major neurocognitive disorder with behavioral disturbance and psychosis. Based on the submitted records, it is not expected that she will improve in a reasonable period of time beyond the dates in question, as she is not having suicidal or homicidal ideation and denies auditory and visual hallucinations. She is compliant with treatment and showing no dangerousness to self or others. It does not appear that active treatment is taking place beyond the dates in question. Continued inpatient psychiatric care is 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 inpatient psychiatric services from January 26, 2022 onward.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lexapro (J8499).

You asked the Plan to pre-approve the Lexapro. The Plan denied your request. The Plan says this drug is not
covered for your condition by Medicare Part B.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Lexapro (J8499).

Benefits for the Lexapro may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied
your request. The Plan says this is not medically necessary.
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 the admission. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled
nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely
and effectively provide medically necessary and reasonable treatment in a SNF. The documentation does not
reveal evidence of complex wound care, new enteral feedings, or other skilled nursing skilled nursing facility
need. The enrollee's functional level does not require skilled therapy services with the specialized skill,
knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and
reasonable treatment in a SNF. The enrollee does not require skilled nursing or skilled therapy services (or a
combination of these services) on a daily basis in the SNF. As a practical matter, this enrollee does not require
the necessary services on an inpatient basis, in a skilled nursing facility 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 the admission have not been met. Therefore, we decided that the Plan does not
have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6545.

You asked the Plan to pre-approve the compression stockings. You say that the item is medically necessary.
The Plan denied your request. The Plan says this member does not have a surgical wound and there
fore does not meet the criteria.

The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6545
are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that
compression bandages and gradient compression wraps are covered only when they are used as dressings over
a qualifying wound.

The record does not show that the enrollee has open venous stasis ulcers or a qualifying wound. This means
that the enrollee does not have a medical condition for which compression stockings can be covered or paid for
by Medicare. Therefore, we decided that the Plan does not have to pre-approve compression stockings
identified with code A6545.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.

You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.

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
enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the
enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an
interdisciplinary approach to rehabilitation care. The enrollee was admitted for COVID 19 pneumonia. Medical
problems are stable. There are no complex nursing or rehabilitation needs.

The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational
therapy, in an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or
occupational therapy, there is no documentation of a need for an intensive rehabilitation program.

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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance transport provided to the enrollee.
You asked the Plan to pay for this transport. You say that this claim should be paid. The Plan denied your
request. The Plan says Medicare billing criteria were not met. Maximus overturned the Plans denial for
insufficient information in the case file to support the denial. The Plan requested a reopen and provided
additional information. The Plan says that the services were billed inappropriately. According to our review,
we found that the provider did not bill the Ambulance Pick-up and Ambulance Drop-off Information for
payment consideration. The Plan included the claim image which shows this.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. Providers must report services with the appropriate codes. In this case, this claim
cannot be paid as billed due to the omission of the appropriate pick-up and drop-off information for the
transport provided. Medicare rules for coverage of this transport have not been met. Therefore, we decided that
the Plan does not have to pay for ambulance transport provided to the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to waive the cost share charged for physician services provided on April 16,
2021.
You asked the Plan to waive this cost share. You say that you do not believe this cost share is correct. The Plan
denied your request. The Plan says this cost share was applied based on your dual eligibility. Maximus
overturned the Plans denial. The Plan requested a reopen and stated this claim was processed towards your
Medicaid coverage. The Plan provided documentation to show that you are Medicaid Eligible and that this
claim was submitted to Medicaid for payment. Any concerns regarding the cost share must be addressed
through Medicaid.
The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all
cost sharing information. Your contract with the Plan clearly says you are a dual eligible member. This claim
was submitted to and processed under your Medicaid benefit. Neither the Plan nor Maximus has the authority
to waive this cost share as we can only review those services applied to your Medicare benefit. Therefore, we
decided that the Plan does not have to waive the cost share charged for physician services provided on April
16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visits provided on October 26, 2020, and October
29, 2020, until they are addressed by the primary payer.
You asked the Plan to pay for these services. You say that these services should be covered for the enrollee.
The Plan denied your request. The Plan says these services must be submitted to the primary payer first for
review. We overturned the Plans denial for insufficient information in the case file regarding the primary
payer responsibility. The Plan requested a reopen and provided the required information. The Plan has also
reached out to obtain an explanation of benefits from the other insurance carrier to show they have reviewed
the claim, but that documentation has not been submitted. Once the Plan has received this information from the
primary payer, they will process this claim.
Based on the information provided with the reopen, we find the Plan is correct in this case. The Plan must
follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee
has another type of insurance. This means that the Plan is not responsible for paying for services until the claim
for those services has gone to the primary insurer. The Plan has provided documentation to show they were not
the primary payer for the enrollee on the dates of service in question. The Plan has also attempted to contact the
primary payer to facilitate further review of these services. As the secondary insurer, the Plan cannot be held
responsible for these services until the primary insurer completed the review for these services. Therefore, we
decided that the Plan does not have to pay for the office visits provided on October 26, 2020, and October 29,
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from
November 08, 2020, to November 09, 2020.
You asked the Plan to pay for these. You say that this claim should be paid. The Plan denied your request. The
Plan says Medicare billing criteria were not met. We overturned the Plans denial for insufficient claim
information in the case file. The Plan requested a reopen. The Plan provided additional information. The Plan
says this claim originally denied because the provider submitted an incorrect bill type. The Plan says that the
Medicare billing guidelines state the claims processing system sets edits to prevent payment on Type of Bill
012x for claims containing certain revenue codes.
The Plan states the claim shows the provider billed a 120 Room-Board/Semi revenue code in line 1. Medicare
guidelines do not allow the billing of this revenue code with the Type of Bill code submitted. This is a specific
edit put in place by the Medicare billing guidelines for providers. The Plan states a corrected claim was
requested.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. Providers must report services with the appropriate codes. In this case the claim
denied due to an issue between the Type of Bill code and the 120 Room-Board/Semi revenue code. The Plan
states a corrected claim would be reviewed if submitted. Medicare rules for coverage of these services have
not been met. Therefore, we decided that the Plan does not have to pay for inpatient hospital services provided
to the enrollee from November 08, 2020, to November 09, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy provided to the enrollee on February 4,
2021.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan says Medicare billing criteria are not met. We overturned the Plans denial for
insufficient information in the case file. The Plan requested a reopen and provided additional information. The
Plan states this claim denied because the provider has billed this service inappropriately. The Plan states this
type of service code is not allowed in an Ambulatory Surgical Center setting. The Plan provided the claim
image which shows the provider has billed this claim with the Place of Treatment as 24 for Ambulatory surgery
center. Physical therapy services are not an allowed service in this setting.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. Providers must report services with the appropriate codes.
In this case, this claim cannot be paid as billed due to an error with the place of treatment code. Medicare rules
for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for
physical therapy provided to the enrollee on February 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A4490.
You asked the Plan to pre-approve the compression stockings. You say that you are appealing this denial. The
Plan denied your request. The Plan says the denial of authorization for these supplies is correct, because these
stockings are not being requested for a qualifying wound and are being used for prevention of deep vein
thrombosis which is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A4490
are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that
compression bandages and gradient compression wraps are covered only when they are used as dressings over
a qualifying wound.
The record does not show that the enrollee has open venous stasis ulcers or a qualifying wound. This means
that the enrollee does not have a medical condition for which compression stockings can be covered or paid for
by Medicare. Therefore, we decided that the Plan does not have to pre-approve compression stockings
identified with code A4490.
Appeal type: Transportation
Decision: Unfavorable

We decided the Plan does not have to pay for facility to facility ambulance transport provided to the enrollee.
You asked the Plan to pay for this transport. You say that this claim should be paid. The Plan denied your
request. The Plan says payment for this service is the responsibility of the originating facility from which the
enrollee was transported.
We overturned the Plans denial administratively for not providing sufficient information in the case file.
The Plan requested a reopen and provided the required information.
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, the enrollee was transferred from one facility to another while still being
treated as an inpatient. In this case, Medicare requires the facility arranging the transfer to provide coverage for
this transportation as the enrollee remained in inpatient status. The facility is responsible for paying this claim.
Therefore, we decided that the Plan does not have to pay for facility to facility ambulance transport provided to
the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments charged for skilled nursing facility (SNF)
services and inpatient services provided from March 11, 2021, to April 9, 2021.
You asked the Plan to waive this cost share. You say that you do not believe these copayments are correct. The
Plan denied your request. The Plan says these copayments were applied based on the services provided and the
Plan contract agreement. We overturned the Plans denial. The Plan requested a reopen and stated that
we did not apply the correct contract language. The Plan provided additional information regarding this
cost share.
The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all
cost sharing information. Your contract with the Plan clearly says that you must pay a cost share for services
provided. The records show you an admission to a SNF facility prior to the dates in question. There was no
copayment for this service. The prior stay was from January 29, 2021, to February 16, 2021, which was 19
days. You were readmitted to the SNF from March 11, 2021, to March 23, 2021, which was 13 days. This
means you had SNF services for a total of 32 days within a 60-day benefit period. Twenty days were no charge
and 12 days were charged at $100 per day based or $1200 based on the Plan contract agreement.
In addition, you were admitted back to the hospital as an inpatient from March 28, 2021, to April 9, 2021, for
11 days. There is a $200 copayment for days 1 to 6 of an inpatient stay which would have been $1200.
However, because you met your maximum out of pocket during this stay, you were only charged $970.
Based on this new information, 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 copayments charged for skilled nursing facility (SNF)
services and inpatient care provided from March 11, 2021, to April 9, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.  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 enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for peripheral artery disease and infection of the lower extremity and had a below the knee amputation. Medical problems are stable. There are no complex nursing or rehabilitation needs.   The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, in an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program.  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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically necessary for
the enrollee's condition. The Plan denied your request. The Plan says rules for LTACH care have not been met.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
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 the LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found that the enrollee was admitted from her residential skilled nursing facility with
hypercapnic respiratory failure due to stroke and sepsis. The record indicates that the enrollee is ventilator
dependent and comatose, requiring critical care services. The enrollee continues to receive acute care services,
and these have not been denied. The medical record does not indicate that the enrollee requires services that she
is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules
are not satisfied.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to waive the cost share charged for services provided on March 25, 2021.
You asked the Plan to waive this cost share. You say that you do not believe this cost share is correct. The Plan
denied your request. The Plan says this cost share was applied based on your dual eligibility. Maximus
overturned the Plans denial. The Plan requested a reopen and stated this claim was processed towards your
Medicaid coverage. The Plan provided documentation to show that you are Medicaid Eligible and that this
claim was submitted to Medicaid for payment. Any concerns regarding the cost share must be addressed
through Medicaid.
The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all
cost sharing information. Your contract with the Plan clearly says you are a dual eligible member. This claim
was submitted to and processed under your Medicaid benefit. Neither the Plan nor Maximus has the authority
to waive this cost share as we can only review those services applied to your Medicare benefit. Therefore, we
decided that the Plan does not have to waive the cost share charged for services provided on March 25, 2021.