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

 
We decided that the Plan does not have to pay for acute inpatient rehabilitation facility (IRF) admission and 
services. 
 
You asked the Plan to pay for IRF care. The Plan denied your request. The Plan says IRF care 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 pay for 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 that 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 does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. There is not a reasonable expectation that this 
enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. 
 
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 pay for acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided the Plan does not have to pay for any of the testing provided to the enrollee on April 19, 2021.
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 the Medicare billing criteria were not met. Maximus partially overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan noted that code 36253-LT was reprocessed and paid on January 24, 2022, under a previous claim. A copy of the paid claim was submitted with the reopen request. This payment was made prior to the Maximus overturn decision on April 6, 2022. Therefore, this code was previously paid and not part of the denial.
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. Codes 75726 and 75774 are Column 2 codes in relation to code 37244. We asked our coding reviewer to carefully review the case file and apply the relevant Medicare rules to determine whether the use of modifier -59 was clinically appropriate, and if the Plan was correct in denying the request to pay for these codes.
Our reviewer says that the documentation does not support that the services billed with 75726 and 75774 are separately payable from 37244, which is now confirmed to be previously paid. Medicare billing criteria are not met. Therefore, we decided that the Plan does not have to pay this claim as billed.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for these services.
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 the medical records reviewed do not support the services billed. Maximus overturned the Plans denial because they medical records stated to have been reviewed by the Plan were not included in the case file. The Plan requested a reopen and provided the records submitted by your office for review.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. Based on the records provided, there is insufficient information in the record to determine if Medicare rules for coverage the services provided were met.
Therefore, we decided that the Plan does not have to pay for the bone marrow aspiration (20939), arthrodesis (22633) and 22634), posterior segmental instrumentation (22842) and insertion of interbody biomechanical device (22853) provided on April 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits (99203, 99241) with an oncologist to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve office visits with an oncologist. You say that you would like to see the 
requested provider based on medical necessity. The Plan denied your request. The Plan says you must use 
network providers to get your medical care and services. The Plan also says that there are in-network 
oncologists available. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
office visits (99203, 99241) with an oncologist to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of a subcutaneous cardiac rhythm monitor. 
 
You asked the Plan to pre-approve the services. You say that this needs to be removed and replaced because it 
only lasts so long. The Plan denied your request. The Plan says there is no indication that the doctors are 
planning to change medication nor management pending the results of another loop monitor. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that at issue is the medical appropriateness and necessity of replacing the old implanted loop recorder 
(ILR) with a new ILR. The ILR is being requested to allow continued monitoring of the cardiac rhythm. Based 
on current guidelines and the documentation provided, there is insufficient clinical evidence to support the 
medical appropriateness and necessity of replacing the patients old ILR with a new ILR. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve insertion of a subcutaneous cardiac rhythm monitor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee wants to return to being independent and 
they can participate in the therapy sessions. The Plan denied your request. The Plan says the records show that 
the enrollee does not need to be seen by a rehabilitation doctor at least 3 times a week for evaluation of 
functional and medical goals and progress. The services the enrollee needs can be provided safely in other 
settings like a skilled nursing facility, home with home health services or home with outpatient therapy. 
 
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 that 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 respiratory failure and 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, and an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. 
 
There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
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 the IRF admission and services.
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 the enrollee is stable for transport to an 
LTACH, and it will help the enrollee regain maximum independence. The Plan denied your request. The Plan 
says the enrollee's medical needs are being met in the current acute setting. The LTACH would add no 
additional services. With additional time in the current setting, clinical stability can be ensured such that the 
appropriate lower level of care can be determined. 
 
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 does not require services at the LTACH that are not available at the 
acute care hospital where he/she is currently receiving care. All medically necessary care is being provided in 
the current acute care setting.  
 
  There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the health plan. The health plan has approved ongoing care in the current acute care 
setting.  
 
The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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: 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 a skilled nursing facility is unable to 
accommodate the enrollee's needs. The Plan denied your request. The Plan says services could be provided at a 
lower level of care. 
 
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 enrollee appears to be more stable and improving and requires only short-term 
additional acute care hospital services that can safely be administered at the current facility until more 
appropriate for transfer to a lower 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro 2 orthotic device (L8702). 
 
You asked the Plan to pre-approve the orthotic device. You say that the enrollee has been referred by his family 
practice physician for myoelectric orthotic restoration, using MyoPro Motion G. The Plan denied your request. 
The Plan says this item is considered experimental and investigational. Additionally, the supplier of this device 
does not participate with Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules say that experimental and investigational devices are not covered. The 
rules also say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare 
program. 
 
 
 
 We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the orthotic device have not been met. Therefore, we decided that the Plan does not have to pre-
approve the MyoPro 2 orthotic device (L8702).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox. 
 
You asked the Plan to pre-approve Botox. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says Botox is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Botox is only covered for certain indications. 
 
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 Botox. Our reviewer says that the 
documentation does not support that Botox is medically reasonable or necessary. Our physician reviewer found 
the enrollee has a diagnosis of gastroparesis. Based on the Medicare-approved major drug compendia 
gastroparesis is not a medically-accepted indication for use of Botox. The supplied medical records do not 
support that the Botox at issue in this case meets Medicare criteria for medically reasonable and 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 Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Botox.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ultrasonic bone growth stimulator (BGS). 
 
You asked the Plan to pre-approve the BGS. You say that your doctor ordered this BGS in order to help your 
fracture heal due to your osteopenia. The Plan denied your request. The Plan says there is no evidence of a 
nonunion due to lack of serial x-rays. 
 
The Plan must follow Medicare rules. Medicare rules say that BGS may be covered to treat a nonunion of a 
fracture. This nonunion must be documented with two x-rays at least 90 days apart showing no healing. 
 
 
 
 
 
 We looked at the file and Medicare rules. This device was provided before 90 days, and no x-rays were 
submitted to support nonunion. Based on this information, we decided that Medicare rules for coverage of the 
BGS have not been met. Therefore, we decided that the Plan does not have to pre-approve an ultrasonic bone 
growth stimulator (BGS).
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 this is medically necessary. The Plan 
denied your request. The Plan says the request for LTACH is not medically necessary. 
 
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 patient appears to be more stable and improving and should only require 
short-term additional acute care services that can safely be administered at the current facility until more 
appropriate for a lower level of care. The patient does not require services at the LTACH that are not already 
available and covered at the current facility. Transfer to LTACH is not medically necessary as it would not be 
clinically advantageous. Completion of treatment at the current facility is recommended. 
 
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: 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 enrollee will benefit from IRF care that cannot be 
accomplished at a lower level of care. The Plan denied your request. The Plan says under Medicare, the request 
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 that the complexity of the enrollees nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does 
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-
disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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: Outpatient Mental Health
Decision: Unfavorable

We decided the Plan does not have to pay for outpatient mental health care provided on May 15, 2021.
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 the records provided do not support the services billed. Maximus overturned the Plans denial for insufficient information in the case file regarding the Plans denial. The Plan requested a reopen and provided additional information. The Plan demonstrated that based on a review of the available information, the records provided do not support the services billed and do not meet the Medicare LCD criteria for this type of treatment. The records show the enrollee was a resident at a nursing home. The enrollee's situation did not meet these guideline requirements. The enrollee was diagnosed with a mood disorder. No increased risk was reported. The enrollee's mood fluctuated from stable to some sadness when the enrollee discussed tasks or activities he can no longer do. The records show the enrollee could be safely monitored and mood maintained with the previously authorized outpatient mental health care and sessions.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to support the services billed. Based on the medical records, there is insufficient information provided to show the billing of these services met the required Medicare criteria. Therefore, we decided that the Plan does not have to pay for outpatient mental health care provided to the enrollee on May 15, 2021.
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 admission is medically 
necessary. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient care at 
the current hospital. 
 
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 there are no services at the LTACH that the enrollee requires that are not already 
available and covered at the current facility. Our physician reviewer found that transfer to an LTACH is not 
medically necessary as the enrollee is not yet stable. 
 
 
 
 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.