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

 
We decided that the Plan does not have to pay for inpatient hospital services rendered from May 17, 2022, to 
May 25, 2022. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says primary diagnosis code S42.492A was 
replaced with diagnosis code S72.142A. 
 
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 S42.492A. 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 services at issue in this were not supported by the medical records. Our physician 
reviewer found that the enrollee was admitted to the hospital after a ground level fall. The enrollee suffered 
multiple injuries including a hip fracture, and arm fracture and bruising. While both fractures received surgical 
fixation, the hip fracture is a more significant injury and should be billed ahead of the arm fracture. An arm 
fracture alone might be treated as an outpatient, whereas a hip fracture almost always results in hospitalization 
and surgery. As such, the billing of S42.492A as the principal diagnosis 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 rendered from May 17, 2022, to May 25, 2022.
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 an LTACH admission is medically 
necessary. The Plan denied your request. The Plan says the enrollee's needs are being met at the current acute 
setting. 
 
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 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 requested LTACH services are not 
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. All medically 
necessary care is being provided in the current acute care setting. The health plan has approved ongoing care in 
the current acute care setting.  
 
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 is not at functional baseline as she was 
previously independent. You also say the enrollee currently needs assisting with bed mobility, sit to stand, and 
upper body dressing. The Plan denied your request. The Plan says based on Medicare guidelines, the Inpatient 
Rehabilitation Facility (IRF) services you and/or your provider 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 patient's nursing, medical and rehabilitation can be provided in 
a lower level of care and does not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. Our physician reviewer also found that the enrollee requires treatment by multiple therapies, 
including physical therapy and occupational therapy, but this can be provided in 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CDP-SOT provided on July 10, 2023. 
 
You asked the Plan to pay for the CDP-SOT. You say that the CDP-SOT was medically necessary. The Plan 
denied your request. The Plan says a review of the available literature found this testing method, although 
promising, does not have sufficient high-quality evidence to generally support its use. There is not sufficient 
evidence of the test leading to improved overall outcome measurements. The clinical value and effectiveness of 
CDP-SOT has not been demonstrated in the peer-reviewed literature 
 
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 pay for the CDP-SOT. Our reviewer says that the 
requested CDP-SOT is not considered medically reasonable and necessary. Our physician reviewer found the 
enrollee with dizziness. Upon review of currently available literature on this testing method, there was 
insufficient high-quality evidence showing this testing method leads to improved outcomes to support its use at 
this time. Therefore, at this time, the CDP-SOT will be considered not medically 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 CDP-SOT have not been met. Therefore, we decided that the Plan does not 
have to pay for the CDP-SOT provided on July 10, 2023.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for Opioid Treatment Program (OTP) services (G2067, G2078) provided 
on May 1, 2023. 
 
You asked the Plan to pay for OTP services. You say that these services were medically necessary, and no 
precertification or authorization is required for OTP clinic services. The Plan denied your request. The Plan 
says that these services were not performed or referred by a network provider. 
 
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 rationale incorrectly states that this claim was submitted by a physician 
rather than the OTP facility. The claim shows that the billing provider is the OTP facility. This was submitted 
on a professional claim which is allowed according to the rules. The Plan has not provided any information to 
support that they have an in-network OTP facility which would have been able to perform these services. As 
such, we find that the Plan has not substantiated this denial of payment. Therefore, we decided that the Plan has 
to pay for Opioid Treatment Program (OTP) services (G2067, G2078) provided on May 1, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular artery embolization. 
 
You asked the Plan to pre-approve genicular artery embolization. You say that this may be of significant 
benefit to the enrollee. The Plan denied your request. The Plan says this procedure is unproven and not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve genicular artery embolization. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found genicular artery embolization is experimental for knee pain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genicular artery embolization have not been met. Therefore, we decided that the 
Plan does not have to pre-approve genicular artery embolization.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Repatha Sureclick. 
 
You asked the Plan to pre-approve the medication. You say that Repatha Sureclick is medically necessary. 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 Repatha Sureclick.   
Benefits for the medication 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: Home Health
Decision: Favorable

 
We decided that the Plan has to pre-approve 6 home health physical therapy visits. 
 
You asked the Plan to pre-approve 6 home health physical therapy visits. You say that you would like to 
request reconsideration of the denied home health physical therapy visits and that the services requested are 
medically necessary. The Plan denied your request. The Plan says that the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health physical therapy visits. 
Our reviewer says that the services are medically reasonable and necessary. Our physician reviewer found the 
enrollee suffered thoracic spine compression fractures and rib fractures requiring placement of a TLSO brace. 
They have been receiving physical therapy to improved strength and mobility. The enrollee continues to have 
strength deficits in the lower extremities and impaired standing balance and ambulation. The enrollee would 
benefit from additional physical therapy to improve their gait and balance and fall prevention. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health physical therapy visits have been met. Therefore, we decided that 
the Plan has to pre-approve the requested home health physical therapy visits.   
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electrical connection (E2311), expandable controller
(E2377), and harness (E2313) for the enrollee.

You asked the Plan to pre-approve the requested upgraded electronics. You say that the requested upgraded
electronics are medically necessary. 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 that
Maximus did not apply the correct criteria. The Plan noted that toggle switches come included with the
approved power option(s) and power feature(s). The medical records show the enrollee has more than adequate
strength in both shoulders, both elbows and both wrists and hands operate the switches that come with the
approved power wheelchair. The records provided do not support the need for upgraded electronics in the case.

The Plan is correct in this case. The available clinical documentation in the case file does not support that the
requested expandable controller, harness, and electronic connection were medically reasonable and necessary
for the enrollee in this case. The notes do not show the medical necessity of controlling the power options
through a joystick. Therefore, we decided that the Plan does not have to pre-approve an electrical connection
(E2311), expandable controller (E2377), and harness (E2313) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for an upright walker or up-walker (E0144).

You asked the Plan to provide coverage for an upright walker. You say that this walker is medically necessary.
The Plan denied your request. The Plan says an upright walker or walker with standing or enclosed frame is not
covered by Medicare. Maximus overturned the Plans denial. The Plan requested a reopen and provided
additional information. The Plan noted again that this type of walker is not covered by Medicare.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules specifically state that a
walker with an enclosed frame, which is considered an upright walker, is not covered by Medicare. You
requested an upright walker. Therefore, we decided that the Plan does not have to provide coverage for an
upright walker or up-walker (E0144).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377) with harness (E2313) 
and electronic connection (E2311). 
 
You asked the Plan to pre-approve an expandable controller with harness and electronic connection. You say 
that the request is a medical necessity for the enrollee. The Plan denied your request. The Plan says the 
requested items are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an expandable controller with harness 
and electronic connection. Our reviewer says that the requested items are not considered medically reasonable 
and necessary in this case. Our physician reviewer found that the requested electrical accessories are not 
medically necessary as the enrollee does have use of the upper extremity and can operate and control the power 
options using the switches that are included in the basic wheelchair. 
 
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 expandable controller with harness and electronic connection have not been 
met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377) with 
harness (E2313) and electronic connection (E2311).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for an expandable controller (E2377), with harness
(E2313), and electronic connection (E2311).

You asked the Plan to provide coverage for these upgraded accessories. You say that these additional
accessories are medically necessary. The Plan denied your request. The Plan says the Medicare coverage
criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and noted that
Maximus did not apply the correct criteria. The Plan stated that the management of power features using a
single joystick controller, rather than through their own switches, is not reasonable and necessary in this
enrollee's case. The medical records show the enrollee is independent with daily activities and can use the
standard switches.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that items and
services that are not medically necessary are not covered. The available clinical documentation does not
support that the requested expandable controller, harness, and electronic connection were medically reasonable
and necessary for the enrollee. The records do not show the medical necessity of controlling the power options
through a joystick. Therefore, we decided that the Plan does not have to provide coverage for the expandable
controller (E2377), with harness (E2313), and electronic connection (E2311).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 4 additional home health skilled nursing visits and 3 
additional physical therapy visits. 
 
You asked the Plan to pre-approve home health services. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the enrollee is 
noted to be medically stable. The enrollee does not require wound care, catheterization, G-tube feeding, or 
administration of intravenous or complex medications. The enrollee has been educated regarding their 
medications and they have not recently been hospitalized. The enrollee is modified independent with mobility 
and transfers may require some degree of assistance and supervision with daily activities, but their level of 
function has not significantly changed and they no longer requiring ongoing skilled physical therapy. 
Therefore, the continued home health skilled nursing care and physical therapy is not medically 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 4 additional home health skilled nursing visits and 3 additional physical therapy 
visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a replacement socket, below knee, molded to patient
model (L5700) for a prothesis.

You asked the Plan to pre-approve a replacement socket, below knee, molded to patient model (L5700). You
say that this prosthetic equipment is medically necessary. The Plan denied your request. The Plan says the
Medicare coverage criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and
stated that Maximus did not apply the correct criteria. The Plan noted that the actual medical records show no
documentation stating you required the features of the requested knee versus a mechanical knee. The requested
microprocessor knee exceeds your needs and is not reasonable and necessary per Medicare criteria.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that for Medicare to
consider coverage and payment for any item or service, the information submitted by the supplier or provider
must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare
coverage criteria have been met. Medicare has specific coverage criteria for prosthetic equipment and will not
cover items that exceeds an enrollee's ambulation needs. We looked at the file and Medicare rules. Based on
this information, we decided that there is insufficient information in the record to determine if Medicare rules
for coverage of the requested equipment are met. Therefore, we decided that the Plan does not have to preapprove
a replacement socket, below knee, molded to patient model (L5700) for a prothesis.