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

 
We decided that the Plan does not have to change the enrollees co-pay billed for the PT services provided on 
June 29, 2022. 
 
You asked the Plan to change the enrollees co-pay billed for the PT services. You say that the enrollee should 
be charged for an in-network provider. Plan denied your request. The Plan says that the co-pay billed was 
correct. 
 
Maximus provides independent review for coverage disputes between Plans and enrollees. A coverage dispute 
is one in which the Plan does not pay for or approve an item or service because it believes that the item or 
service is not covered by Medicare and is not covered as an additional benefit under the terms of the Plans 
Evidence of Coverage. A non-contract provider who has been denied payment may appeal to the Plan if the 
provider executes a waiver of liability. 
 
A claim processing dispute is one in which the Plan agrees that the service is covered, but the amount of 
payment is in dispute. We have looked at your request and have determined it is a claim processing dispute 
rather than a coverage dispute. Maximus does not have jurisdiction over these issues. You may contact the New 
York CMS Regional Office at 212-616-2222 with any questions you have about this dispute. Therefore, we 
decided that the Plan does not have to change the enrollees co-pay billed for the PT services provided on June 
29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and the electrocardiogram provided on March 
13, 2023. 
 
You asked the Plan to pay for the office visit and the electrocardiogram. You say that you are requesting 
reconsideration of the denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the office visit and the 
electrocardiogram provided on March 13, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient T11 and T12 Kyphoplasty (22514, 22515).  
 
You asked the Plan to pre-approve T11 and T12 Kyphoplasty. You say that this service is medically necessary. 
The Plan denied your request. The Plan says in this case, the enrollee has evidence of other pain generating 
fractures.  
 
The Plan follows Medicare rules. Medicare rules say that Kyphoplasty is covered when the criteria in the rules 
section of this letter are met. 
 
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 T11 and T12 Kyphoplasty. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found that detailed 
documentation is not evident regarding worsening pain. There is no indication of a progression of the body 
height loss, greater than 25% vertebral body height loss at all levels, or a severe impact on her daily activities. 
Moreover, there is CT corroboration of other plausible causes of pain. Therefore, the enrollee does not meet 
LCD coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of T11 and T12 Kyphoplasty have not been met. Therefore, we decided that the 
Plan does not have to pre-approve outpatient T11 and T12 Kyphoplasty (22514, 22515).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Myrbetriq. 
 
You asked the Plan to pre-approve Myrbetriq. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
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 Myrbetriq.   
Benefits for Myrbetriq 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a rotation unit (K1022). 
 
You asked the Plan to pre-approve a rotational unit. You say that the item is medically necessary. The Plan 
denied your request. The Plan says this item does not serve a medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a rotation unit (K1022).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you were independent prior to hospitalization and 
need aggressive rehabilitation. The Plan denied your request. The Plan says the criteria for IRF admission was 
not met and the enrollee's needs can be met at a lower-level setting like at a skilled nursing facility. 
 
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 hip replacement surgery. 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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF services are medically necessary for the 
enrollee. The Plan denied your request. The Plan says  the criteria for IRF admission was not met and the 
enrollee's needs can be met at a skilled nursing facility. 
 
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 pleural effusion and pericardial effusion. 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 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 inpatient rehabilitation is both physically and 
medically necessary for the enrollee to return home at their maximum level of functioning with a decreased risk 
for readmission. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria 
for an 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 
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. 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. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that no other machine has the mode like the 
trilogy device. It is used in this mode to help those with qualifying factors like this enrollee with her severe 
COPD. The Plan denied your request. The Plan says the request for a non-invasive ventilator (NIV) is not 
medically necessary because the documentation does not support that this device meets but does not exceed the 
enrollee's need. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 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 a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the record indicates that the enrollee 
has chronic hypercapnic respiratory failure from chronic obstructive pulmonary disease. The record indicates 
that the enrollee was successfully treated with bilevel positive airway pressure (BiPAP) in the hospital. The 
provided primary source documentation does not contain sufficient detailed information in the medical record 
to justify the treatment selected. The enrollee could be treated with a BiPAP machine with average volume-
assured pressure support (AVAPS) capability and failure of such a device has not been documented. The 
elements of the coverage criteria are not satisfied. The requested service cannot be 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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for inpatient hospital stay and skilled nursing 
facility (SNF) care on January 18, 2023, to February 13, 2023. 
 
You asked the Plan to waive the copayments for inpatient hospital stay and SNF care. You say that you want to 
appeal the amount being charged. 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 $295 copayment per day, days 18; $0 per day, days 990; $0 copay for additional days for each 
medically necessary covered inpatient stay. Includes inpatient acute, inpatient rehabilitation, longterm care 
hospitals and other types of inpatient hospital services. Inpatient hospital care starts the day you are formally 
admitted to the hospital with a doctors order. The day before you are discharged is your last inpatient day. 
Enrollees must pay a $20 copayment per day, days 1 20; $196 per day, days 21 100 for each Medicare covered 
SNF stay. Days covered: up to 100 days per benefit period. A prior hospital stay is not required. We will only 
cover your stay if you meet certain Medicare guidelines, and your stay is medically necessary. Costsharing is 
not charged on the day of discharge. The Plan is only charging for days 1-4 for inpatient hospital stay. 4 x $295 
= $1,180. For SNF stay there were eleven days.11 x $20 = $220.00. For both services it's, $1,180 + $220 = 
$1,400. Therefore, results in the total cost sharing amount of $1,400. 
 
The enrollee has been asked to pay a $295 copayment per day for inpatient hospital stay and a $20 copayment 
per day for SNF care. This item/service falls within the inpatient hospital care and skilled nursing facility 
(SNF) care benefit category. This means that the enrollee has been 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 copayments for inpatient 
hospital stay and skilled nursing facility (SNF) care on January 18, 2023, to February 13, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the DecisionDx-SCC test provided on January 16, 2023.  
 
You asked the Plan to pay for the DecisionDx-SCC test. You say that the DecisionDx-SCC test is medically 
necessary. The Plan denied your request. The Plan says that the DecisionDx-SCC test is not medically 
necessary.  
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the DecisionDx-SCC test. Our reviewer says 
that the requested DecisionDx-SCC test is considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee was found to have squamous cell carcinoma of the LEFT central 
zygoma and LEFT superior central malar cheek. DecisionDx-SCC assay is a prognostic 40-gene expression 
profile (40-GEP) test, was developed and validated. The 40-GEP assay utilizes RT-PCR gene expression 
analysis on primary tumor biopsy tissue to evaluate the expression of 34 signature gene targets and 6 
normalization genes. The test provides classifications of low risk (Class 1), moderate risk (Class 2A), and high 
risk (Class 2B) of metastasis within 3 years of diagnosis. DecisionDx-SCC demonstrates a high degree of 
analytical precision, yielding high concordance rates across multiple performance experiments, along with 
exhibiting robust technical reliability on clinical samples. The review has determined that the requested 
DecisionDx-SCC test at issue in this case is 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 the DecisionDx-SCC test have been met. Therefore, we decided that the Plan 
has to pay for the DecisionDx-SCC test provided on January 16, 2023.   
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: 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 has been making significant progress in 
therapy and is ready for discharge. The Plan denied your request. The Plan says the IRF services you are 
requesting do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an auricular nerve stimulator. 
 
You asked the Plan to pre-approve an auricular nerve stimulator . You say that this is medically necessary. The 
Plan denied your request. The Plan says this is considered experimental. 
 
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 an auricular nerve stimulator. Our 
reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our 
physician reviewer found this is considered experimental. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an auricular nerve stimulator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an auricular nerve stimulator.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from September 10, 2022, 
to October 9, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 
 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from September 10, 2022, to 
October 9, 2022.