Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 sensor. 
 
You asked the Plan to pre-approve a Dexcom G6 sensor. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the enrollee does not meet criteria for the requested item. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
Dexcom G6 sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Dexcom G6 sensor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are requesting LTACH placement 
for hopeful optimization of health prior to discharging the enrollee home with hospice. The Plan denied your 
request. The Plan says based on Medicare guidelines the long term acute care hospital services you are 
requesting do not meet the requirements for approval. 
 
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 the record indicates that the enrollee continues to have acute medical issues and still 
requires acute care services before transitioning to a lower level of care. The medical record does not indicate 
that the enrollee requires services not currently receiving but that would be available at the LTACH facility. 
 
 
 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 the LTACH services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home psychotherapy visits. 
 
You asked the Plan to pre-approve the home psychotherapy visits. You say that the enrollee does not have a 
driver's license and is a caregiver to her son. You also say that the enrollee suffered a fall at home that keeps 
her walking with a walker. The Plan denied your request. The Plan says the service is not medically necessary 
as the enrollee's physical or mental health does not make it impossible to attend mental health visits and leaving 
home is not medically contraindicated. 
 
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 the psychotherapy visits. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found based on review of the records provided, documentation does not show the enrollee 
to be homebound and does not require home health psychological services. 
 
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 psychotherapy visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home psychotherapy visits.
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 services are medically necessary to address the 
enrollee's complex medical comorbidities which resulted in functional impairments and increased risk for 
medical instability. The Plan denied your request. The Plan says the enrollee's needs can be met at a skilled 
nursing facility, with home health care or outpatient therapy services. 
 
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 the enrollee has active medical issues and complex functional impairments. However, 
the neurological evaluation does not specifically show that the enrollee would be able to tolerate intense 
therapy or 15 hourrs of therapy per week. 
 
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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that this admission is medically necessary. The Plan 
denied your request. The Plan says an IRF admission is not medically necessary. 
 
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 the enrollee is frail and has cognitive loss. He cannot fully participate in or benefit 
from intensive rehabilitation and does not require intensive services.  
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on August 3, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related 
laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on August 
3, 2022.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for enteral formula provided from July 12, 2022, to 
July 31, 2022. 
 
You asked the Plan to pay for enteral formula. You say that the patient was discharged from hospice on  
July 5, 2022. The Plan denied your request. The Plan says Original Medicare would be responsible for payment 
only for services rendered from July 12, 2022 through July 31, 2022 of all Medicare covered services related or 
unrelated to the members terminal condition rendered during Hospice revocation month. The Medicare 
hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to 
the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending 
physician services and all care unrelated to the terminal illness until the first day of the month following the 
month in which hospice was revoked or discharged. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on July 5, 2022. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for enteral formula provided 
from July 12, 2022, to July 31, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the computer-assisted surgical navigational procedure 
for musculoskeletal procedures (20985). 
 
You asked the Plan to pre-approve the computer-assisted surgical navigational procedure for musculoskeletal 
procedures. You say that the requested computer-assisted surgical navigational procedure for musculoskeletal 
procedure (20985) is medically necessary. The Plan denied your request. The Plan says the requested 
computer-assisted surgical navigational procedure for musculoskeletal procedure (20985) is 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 the computer-assisted surgical 
navigational procedure for musculoskeletal procedures. Our reviewer says that the requested computer-assisted 
surgical navigational procedure for musculoskeletal procedure (20985) is not medically necessary. Our 
physician reviewer found the enrollee was being treated for primary osteoarthritis of the right knee. He 
presented with pain along the anteromedial aspects of the bilateral knees. He has global aching and discomfort 
in the knees. He has a sense of instability bilaterally that seems to have increased in the past several months. 
The right knee still bothers him after the Synvisc one injection on August 23rd. He notes instability, catching, 
and locking in the right knee. The exam of the right knee reveals range of motion from 0-120. There is varus 
deformity that is passively correctable to neutral. He has 1+ medial but no significant lateral joint line 
tenderness. 
 
However, there are no large-volume, long-term/high-quality clinical studies that confirm clinical benefits 
(ultimate outcomes of functional improvement and pain reduction) of computer-assisted surgery over standard 
surgical approaches in partial knee arthroplasty. There is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested 
computer-assisted surgical navigational procedure for musculoskeletal procedure (CPT 20985), in this case, is 
not medically reasonable or 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 the computer-assisted surgical navigational procedure for musculoskeletal 
procedures have not been met. Therefore, we decided that the Plan does not have to pre-approve the computer-
assisted surgical navigational procedure for musculoskeletal procedures (20985).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code K1019 billed for date of service June 29, 
2022. 
 
You asked the Plan to pay for procedure code K1019. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.   
In this case, the MUE for CPT code K1019 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code K1019 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code K1019 billed for date of service June 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a micro-processor knee.
You asked the Plan to provide coverage for a micro-pressor knee. You say that this prosthetic component is
medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria for this
component were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that
Maximus did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for a micro-processor
knee. The Maximus Physician Reviewer determined this request to be medically reasonable. The Plan
requested a reopen and argues the medical records are not consistent. The Plan notes your physician documents
that you are a K3 "potential" ambulator but does not give any reason why a microprocessor knee is medically
necessary. The provider's notes do not show why a mechanical K3 knee cannot be used for the initial
prosthesis, especially given the weight a microprocessor knee. Providers notes do not give any medical reason
why a microprocessor K3 knee is medically necessary, and why a mechanical K3 knee will not meet your
needs. The medical records show you have a history of diabetes and peripheral vascular disease and underwent
a right above-knee amputation. The Plan is correct in this case. There is insufficient clinical documentation of
functional need for the technologic or design features of a microprocessor knee in this case.
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 micro-pressor knee have not been met. Therefore, we decided that the Plan
does not have to provide coverage for a micro-processor knee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on October 4, 2021.
You asked the Plan to pay for this testing. You say that this testing should be covered by the Plan. The Plan
denied your request. The Plan says Medicare billing criteria were not met.
Maximus overturned the Plans denial. The Plan requested a reopen and notes that the claim was billed with a
date of service inconsistent with Medicare rules governing laboratory services. The records show the specimen
was collected on August 16, 2021; however, the billed date is October 4, 2021. The date of service for a
clinical laboratory test or the technical component of physician pathology service must be the date the
specimen was collected.
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 could not be paid due to inconsistency with the dates of service
billed. Medicare rules for coverage of this testing have not been met. Therefore, we decided that the Plan does
not have to pay for genetic testing provided to the enrollee on October 4, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on January 3, 2022.
You asked the Plan to pay for this testing. You say that this testing should be covered by the Plan. The Plan
denied your request. The Plan says Medicare billing criteria are not met. Maximus overturned the Plans denial.
The Plan requested a reopen and stated that the claim did not include the required test identifier. Also, the claim
was billed with a date of service inconsistent with Medicare rules governing laboratory services. The records
submitted show that a specimen was collected on December 9, 2021. There is no documentation of molecular
pathology testing performed on the date billed: January 3, 2022.
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 cannot be paid as billed due to the omission of the required test
identifier and inconsistencies with the date of service billed and the date the specimen was collected. Medicare
rules for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay
for genetic testing provided to the enrollee on January 3, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on February 5, 2022.
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that there is no documentation of genetic testing performed on February 5, 2022. The claim billed with a date of service inconsistent with Medicare rules governing laboratory services. The records submitted show that a specimen was collected on December 23, 2021. There is no documentation of molecular pathology testing performed on the date billed: February 5, 2021. Also, the claim did not include the required testing identification code.
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 could not be paid as billed due to issues with the dates of service reported and the omission of required testing identifier codes. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing provided to the enrollee on February 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for bioimpedance spectroscopy for the enrollee.
You asked the Plan to provide coverage for this treatment. You say that at the time of the appeal, this treatment
was medically necessary for the enrollee. The Plan denied your request. The Plan says Medicare coverage
criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that
Maximus did not apply the correct criteria.
Our Medical Director look at the case file and the reopen request. At issue is coverage for bioimpedance
spectroscopy (BIS) assessment using the ImpediMed L-Dex testing device. The Maximus Physician Reviewer
determined the treatment was reasonable in this case. The Plan requested a reopen and stated that the rules say
that services that are not medically necessary are not covered. The Plan is correct in this case. The NCCN
Guidelines Version 1.2022 Survivorship: Lymphedema does not recommend BIS in the management of
lymphedema. The evidence in the medical literature and the clinical documentation in this case are insufficient
to support that bioimpedance spectroscopy is medically reasonable and necessary for this enrollee. We looked
at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare
rules for coverage of this treatment have not been met. Therefore, we decided that the Plan does not have to
provide coverage for bioimpedance spectroscopy for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for genetic testing provided to the enrollee on February 22, 2022.
You asked the Plan to pay this claim. You say that these services should be covered by the Plan. The Plan
denied your request. The Plan says Medicare billing criteria are not met.
Maximus overturned the Plans denial. The Plan requested a reopen and notes that the claim was billed with a
date of service inconsistent with Medicare rules governing laboratory services. The records submitted show a
specimen was collected on February 2, 2022, however, there is no documentation to support genetic testing was
performed on February 22, 2022.
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 cannot be paid as billed due to an inconsistency with the dates
of service billed. Medicare rules for coverage of this claim have not been met. Therefore, we decided that the
Plan does not have to pay for genetic testing provided to the enrollee on February 22, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on March 14, 2022.
You asked the Plan to pay for this testing. 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.
The Plan requested a reopen and noted that the claim was billed with a date of service inconsistent with Medicare rules governing laboratory services. The records submitted show that a specimen was collected on June 22, 2021. There is no documentation of molecular pathology testing performed on the date billed of March 14, 2022. In addition, the claim was submitted without a testing identifier code.
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 could not be paid due to a discrepancy with the dates of service versus the date the specimen was collected as well as the omission of a required identifier. Medicare rules for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing provided to the enrollee on March 14, 2022.