Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided the Plan does not have to provide coverage for 12 additional physical therapy visits for the enrollee.
You asked the Plan to provide coverage for 12 additional visits. You say that at the time of the appeal, this treatment was medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria for additional therapy visits were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.
The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.
Based on the medical record provided, the enrollees condition no longer required the oversight of a trained therapist and could continue with a home exercise program. Medicare rules for coverage of this request have not been met. Therefore, we decided that the Plan does not have to provide coverage for 12 additional physical therapy visits for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to provide coverage for IRF care. You say that at the time of the appeal, IRF admission was medically necessary. 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 coverage criteria.
The Plan is correct in this case. 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. The medical records do not show that at the time of the appeal, you had the physical ability to participate in an intensive rehabilitation therapy program at least three hours per day for at least five days per week.
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on March 17, 2022.
You asked the Plan to pay for this testing as billed. You say that this testing should be covered by the Plan. The Plan denied your request. The Plan says the Medicare billing criteria were not met.
Maximus overturned the Plans denial stating the Plan used the incorrect billing guidelines for jurisdiction. The Plan requested a reopen and notes that box 32 of the claim form "Name and Address of Facility Where Services Were Rendered" clearly states that services were rendered. This locality was also supported by the laboratory report which identifies that the "Sample Preparation" and "Sample Analysis" were both performed. Billing and Coding: MolDX: Molecular Diagnostic Tests (MDT) (A56853) is applicable to jurisdiction. Additionally: The Plan also notes the claim was billed with a date of service inconsistent with Medicare rules governing laboratory services. The Plan states the claim was billed with a date of service inconsistent with Medicare rules governing laboratory. The records submitted show that a specimen was collected on February 23, 2022. There is no documentation of molecular pathology testing performed on the date billed: March 17, 2022. The claim did not include all the documentation to process the claim. The required DEX Z-Code was not provided and the claim was billed with a place of service (POS) 81, Independent Laboratory, independent of an institution or a physician's office. An independent laboratory taking a sample in its laboratory shows "81" as place of service. The sample was collected in the provider's office/outpatient facility/hospital. There is no documentation that the sample was taken by the laboratory directly Medicare Guidance Says: No payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period. 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. Providers must report services with the appropriate codes. In this case the claim could not be paid as billed due to issues with the dates of service reported, the POS code reported and the omission of the required test identifier code. Medicare rules for coverage of this testing as billed have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing provided to the enrollee on March 17, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for genetic testing provided to the enrollee on February 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 the Medicare billing criteria were not met.
Maximus overturned the Plans denial stating the testing was medically necessary. The Plan requested a reopen and stated that the issue was not medically necessity but an issue with billing errors on the claim. The Plan notes that the claim was billed with a date of service inconsistent with Medicare rules governing laboratory services. The specimen was collected on August 13, 2021, rather than the billed date of service February 14, 2022. 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 also notes the claim did not include the required DEX Z-Code (test identifier).
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 denied due to errors with the date of service reported versus the date the specimen was collected and the omission of the required test 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 February 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye surgery provided on March 30, 2022.
You asked the Plan to waive the copayment for the eye surgery. You say that you only think you should have been charged one copayment. 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 a $250 copayment for outpatient procedures and services.
You have been asked to pay a $250 copayment for the eye surgery. This item/service falls within the outpatient procedures and services 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 the eye surgery provided on March 30, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for genetic testing provided to the enrollee on February 10, 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 the Medicare billing criteria were not met.
Maximus overturned the Plans denial for medical necessity. The Plan requested a reopen and stated the issue
was not medical necessity but the fact that the claim was submitted with billing errors. The Plan notes that this
is an administrative determination for non-coverage and is not based on clinical criteria for medical necessity.
The claim did not include all the documentation to process the claim. The required DEX Z-Code (test
identifier) was not provided. In addition, the claim was billed with a date of service inconsistent with Medicare
rules governing laboratory services. The specimen was collected on January 19, 2022, rather than the billed
date of service February 10, 2022. 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 was submitted with errors regarding the dates of service versus
the date of specimen collection and the omission of the required identifier code. 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 February 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a new walker with seat. 
 
You asked the Plan to pre-approve the walker. You say that you lost your walker. The Plan denied your 
request. The Plan says the medical records should contain the date of loss/damage along with a copy of the 
police report or insurance claim. 
 
The Plan must follow Medicare rules. Medicare rules say equipment which the beneficiary owns or is a capped 
rental item may be replaced in cases of loss or irreparable damage. 
 
There is no evidence that the original walker was lost or irreparably damaged in the case file. Based on this 
information, we decided that Medicare rules for coverage of the walker have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a new walker with seat.
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 the service is medically necessary. The Plan denied 
your request. The Plan says 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 complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  
 The enrollee continues to have a need for skilled therapy with ongoing safety concerns and a potential for 
functional improvement however, the documentation doesn't support they would meet criteria for admission to 
an acute inpatient rehabilitation facility. There is no indication that the enrollee would require skilled 
rehabilitation in an IRF, participating in rehabilitation services 15 hours a week, under the supervision of a 
physician with at least 3 visits weekly to regain or maintain functional status. The enrollee can receive further 
services at 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 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 pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is unable to care for himself and needs 
24-hour care. The Plan denied your request. The Plan says based on Medicare guidelines the inpatient 
rehabilitation facility 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 the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  The enrollee was admitted for seizure disorder. Medical problems are stable. There are no complex nursing or 
rehabilitation needs. While the medical records support 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 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 IRF admission and services.
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 the enrollee would like reconsideration because the 
services are medically necessary. The Plan denied your request. The Plan says an IRF admission is not 
medically necessary, and the enrollee's needs can be met at an alternate level of care. 
 
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 enrollees 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
July 14, 2022. 
 
You asked the Plan to waive the copayment for the emergency room (ER) visit. You say that the enrollee 
refused services and went to a VA hospital. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $90 copayment for emergency care.  
 
The enrollee was asked to pay a $90 copayment for the emergency room (ER) visit. This item/service falls 
within the emergency care benefit category. This means that the enrollee was asked to pay the correct amount 
based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay 
upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an 
emergency room (ER) visit provided on July 14, 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 the enrollee requires full oversight with physical 
therapy and doctor on site due to his various medical conditions.  The Plan denied your request. The Plan says 
based on Medicare guidelines and the information we have about the enrollees condition they do not meet all 
the requirements. 
 
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 complexity of the enrollees nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for knee pain after recent knee replacement surgery. Medical problems are stable. There are no 
complex nursing or rehabilitation needs. While the medical records support 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 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: 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 the services requested are medically necessary. The 
Plan denied your request. The Plan says that the criteria for admission to SNF have 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 documented skilled nursing needs. The enrollees 
feeding tube is established. The enrollee is progressing with his current therapy. The enrollee can complete his 
current course of therapy before being discharged to 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
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 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 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 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 IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee would benefit from inpatient 
rehabilitation services due to their medical complexity. The Plan denied your request. The Plan says the 
enrollee's needs can be met in another setting such as skilled nursing facility (SNF) or home with home health 
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 there are no complex nursing or rehabilitation needs. While you have a need for 
physical 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 IRF admission and services.