Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nursing home visit provided on April 4, 2023, by an out-of-
network (OON) provider.  
 You asked the Plan to pay for the nursing home visit. You say that the doctor was treating any residents in the 
nursing home that needed treatment and would not turn down a patient due to an insurance issue. The Plan 
denied your request. The Plan says their original decision to deny payment was correct. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a nursing home visit provided on April 4, 2023, by 
an out-of-network (OON) provider.
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 you are requesting an expedited 
reconsideration as the enrollee currently meets LTACH admission criteria. The Plan denied your request. The 
Plan says the enrollee does not meet the guidelines for care in the LTACH. 
 
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 improving but is still unstable and requires additional 
acute care hospital services that can safely be provided at the current facility until more stable and appropriate 
for transfer. There are no services at the LTACH that the enrollee requires that are not already available and 
covered at the current facility. Transfer to the LTACH would not be clinically advantageous at this time (total 
parenteral nutrition, restraints) and 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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for psychotherapy provided from June 28, 2023, to 
July 19, 2023.  
 
You asked the Plan to reimburse you for the psychotherapy. You say that you tried calling in-network 
providers and nobody was able to get you in until after the first of the year. You say that you were dealing with 
extreme depression and did not feel that you could wait seven months to deal with your depression. The Plan 
denied your request. The Plan says except for emergency care, we cannot pay a provider who is not eligible to 
participate in Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that a Licensed Professional Counselor is not eligible 
to participate in the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue in this case is a Licensed Professional 
Counselor. Medicare says that a Licensed Professional Counselor is not eligible to participate in the Medicare program. Therefore, we decided that the Plan does not have to reimburse you for psychotherapy provided from 
June 28, 2023, to July 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction provided on June 20, 2023. 
 
You asked the Plan to pay for the eye refraction. You say that you were referred by your nurse practitioner to 
determine if a condition behind your eyes might contribute to the problems you have developed with your 
memory. The Plan denied your request. The Plan says an eye refraction performed in conjunction with 
Medicare covered eye exams are not covered. An eye refraction is only covered when performed during a 
routine vision exam.  
 
The Plan must follow Medicare rules. Medicare does not pay for procedures performed in the course of any eye 
exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in 
connection with otherwise covered diagnosis or treatment of illness or injury.  
 
We looked at the file and the Medicare rules. Medicare does not pay for procedures performed in the course of 
any eye exam to determine the refractive state of the eyes. Medicare does not cover refractive procedures even 
when done in connection with otherwise covered diagnosis or treatment of illness or injury. Therefore, we 
decided that the Plan does not have to pay for an eye refraction provided on June 20, 2023.
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 was in a skilled nursing facility and was 
not give quality care. You also say that he was supposed to get physical therapy for walking and was only 
given speech therapy and training on how to button his shirt and shoes. The Plan denied your request. The Plan 
says based on Medicare guidelines, the inpatient rehabilitation facility services requested 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 at the time of the request for an IRF admission, the enrollee was receiving home 
health services. The review has determined that 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 does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy 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: 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 the enrollee's prior admission level of 
function was independent, they live alone and need the extensive physical and pulmonary therapy to reach their 
goals. The Plan denied your request. The Plan says criteria for admission to the LTACH 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 the enrollee appears to be improving and should only require short-term 
additional acute care hospital services that can safely be provided at the current facility until more stable and 
appropriate for transfer to a lower level of care. There are no services at the LTACH that the enrollee requires 
that are not already available and covered at the current facility. Transfer to the LTACH would not be clinically 
advantageous at this time and 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a replacement spinal cord stimulator.

You asked the Plan to provide coverage for this device. The Plan denied your request. The Plan says the
Medicare coverage criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen
and stated Maximus did not apply the correct criteria. The Plan noted that while you had undergone SCS
placement previously, three years had passed since the previous trial, which was complicated by the
development of an infection. In the interim, the medical records show the enrollee you reported multiple active
psychiatric conditions including bipolar disorder, PTSD, alcoholism, unspecified drug addiction and
depression. The medical records show your physician expressed concern regarding the appropriateness of SCS
reimplantation. The notes state it was explained to you that prior to implantation, you would first need to have
evaluation by infectious disease and evaluation of your psychological status. The Plan states considering these
factors, the required criteria for permanent spinal cord stimulator implantation were not met.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare has specific coverage criteria
for the permanent implantation of a spinal cord stimulator. Based on the medical records provided, you did not
meet the criteria at the time of the appeal. Therefore, we decided that the Plan does not have to provide
coverage for a replacement and permanent placement of a spinal cord stimulator.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the refraction service (92015), eye exam (92004), ophthalmic 
diagnostic imaging (92134), and correction of trichiasis (67820) provided on June 15, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the vision services. You say that the services should be covered. The Plan denied 
your request. The Plan says prior authorization was not obtained. 
 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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the refraction service (92015), eye exam (92004), 
ophthalmic diagnostic imaging (92134), and correction of trichiasis (67820) provided on June 15, 2023, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) of the abdomen and pelvis 
with contrast materials (74177) provided on June 12, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the CT scan. You say that you were advised that no authorization was needed. 
You also say that the service was medically necessary. The Plan denied your request. The Plan says services 
performed by an out-of-network provider are 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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) of the abdomen 
and pelvis with contrast materials (74177) provided on June 12, 2023, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health physical therapy and custodial care. 
 
You asked the Plan to pre-approve the home health services. You say that the enrollee has dementia, lives 
alone and needs help with daily life as the enrollee forgets to eat regularly, shower and remember to do daily 
activities. You also say that the enrollee will extremely benefit from other human interaction as she never gets 
out of the house and it leads to sadness. The Plan denied your request. The Plan says the enrollee does not meet 
Medicare criteria for home health physical therapy and there is no clinical documentation that the enrollee is 
homebound. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health services have not been met. Specifically, we find that the services at issue in this 
case are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve home 
health physical therapy and custodial care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office visits to be provided by an OON provider.  
 
You asked the Plan to pre-approve the office visits. You say that you are requesting reconsideration of the 
denied authorization. The Plan denied your request. The Plan says this service is available with in-network 
providers. 
 
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 
the office visits to be provided by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the post-operative follow up visit to be provided by an 
OON provider.  
 
You asked the Plan to pre-approve the post-operative follow up visit. You say that you are requesting 
reconsideration of the denied authorization.  The Plan denied your request. The Plan says this service is 
available with in-network providers. 
 
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 
the post-operative follow up visit to be provided by an OON provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency room services provided on July 7, 2022, and
billed under code 99285.

You asked the Plan to pay for code 99285. The Plan denied your request. The Plan says the Medicare billing
criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and provided
additional clarification. The Plan noted that for code 99285 to be paid the medical records must show a higher-than-
normal degree of care was provided to the enrollee for an emergency room status.

Based on the medical records provided, the enrollee was treated and discharged home in stable condition. The
medical records do not show the enrollee required a high degree of physician care.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. In this case, the medical records provided do not support the billing of code 99285.
Therefore, we decided the Plan does not have to pay for emergency room services provided to the enrollee on
July 7, 2022, and billed under code 99285.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography (CT) scan of the thorax (71250). 
 
You asked the Plan to pre-approve the CT scan. You say that you are requesting reconsideration for the denial 
of a CT scan. The Plan denied your request. The Plan says that the request is not medically reasonable and 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 pre-approve the CT scan. Our reviewer says that the 
service is medically necessary. Our physician reviewer found that CT surveillance for two pulmonary nodules 
greater than 6mm in diameter, noted on a CT scan of February 23, 2022, is a valid reason for the requested CT 
scan of the chest. 
 
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 CT scan have been met. Therefore, we decided that the Plan has to pre-
approve a computed tomography (CT) scan of the thorax (71250).  
 
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 pay for inpatient hospital services provided from January 27, 2023, 
to February 1, 2023 at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
medical records support the DRG originally billed. The Plan denied your request. The Plan says while the 
patient presentation warranted consideration of acute tubular necrosis (ATN) as possible diagnosis there was no 
evidence of FeNa (fractional excretion of sodium) greater than 2%, urinalysis with non-hyaline casts (granular 
or muddy casts or renal tubular cells), urinary sodium greater than 40 mEq/L, or renal biopsy confirmation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with diagnosis code N17.0 (acute kidney failure with 
tubular necrosis). 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 inpatient hospital 
services at the DRG originally billed. Our reviewer says that the DRG originally billed is not medically 
necessary. Our physician reviewer found that the enrollee presented with fatigue. The enrollee was found to 
have Influenza B. The laboratory studies showed mild prerenal azotemia. There is no evidence of overt kidney 
failure or tubular necrosis. There is no evidence that renal issues were addressed during the stay or that a renal 
consultation was obtained. Kidney issues appear to have had no effect on the hospitalization. As such, the 
billing of diagnosis code N17.0 is not supported.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided from January 27, 2023, to February 1, 2023 at the DRG originally 
billed.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a Freestyle Libre 3 continuous glucose monitor (CGM) sensor. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says that the criteria for coverage are not met. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan states that you do not meet the criteria for coverage of a CGM; 
however, no medical records were received with the appeal request. MAXIMUS requested records from your 
physician(s) from the Plan, but a response was not received. Without medical records, a determination based on 
medical necessity criteria cannot be supported. Therefore, we decided that the Plan has to pre-approve a 
Freestyle Libre 3 continuous glucose monitor (CGM) sensor.  
 
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.