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

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided on July 19, 
2023. 
 
You asked the Plan to pay for the skilled nursing facility (SNF) care. You say that you are requesting 
reconsideration for the service provided. 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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 skilled nursing facility (SNF) care provided on July 19, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on August 17, 2023. 
 
You asked the Plan to pay for laboratory services. You say that this service is supported in the records. 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 Plan had network providers available who were capable of providing the items/services at issue in this appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 laboratory services provided on August 17, 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 lives independently and must be able to 
take care of themselves before returning home. The Plan denied your request. The Plan says an IRF admission 
is not medically necessary, but skilled therapies as an outpatient or at a skilled nursing facility (SNF) may be 
approved upon request.  
 
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's 
medical problems are stable and 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 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing (87507) provided to the enrollee on November 29,
2022.

You asked the Plan to pay for the testing. You say that these services were medically necessary. The Plan
denied your request. The Plan says the claim for this molecular pathology testing did not include the required
unique identifier. Maximus overturned the Plan's denial based on lack of information. The Plan requested a
reopening and stated that the claim did not have a unique identifier for the testing. The Plan is correct in this
case. The rules say that for molecular diagnostic tests, such as the test at issue, the MolDX program requires
these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met.
When such review is complete, the test is assigned a unique identifier and the coverage status is listed in the
DEXTM Diagnostics Exchange. The Plan sent in a copy of the claim form submitted. This claim did not have a
unique identifier for the first claim line, which was the line for this testing performed. A unique identifier was
only submitted for the second claim line. Review of the claim does not show that the required unique identifier
was reported for this service. Based on this information, we decided that Medicare rules for coverage of the
testing have not been met. Therefore, we decided that the Plan does not have to pay for the testing (87507)
provided to the enrollee on November 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (CGM) (A4239) provided on 
July 29, 2023. 
 
You asked the Plan to pay for the CGM. You say that the items should be covered as you disagree with the 
denial. The Plan denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
 The record does not contain a valid physician order or current and relevant medical records which support 
medical necessity for the supplies provided in this case.The medical records show the exam visits date of 
service is over a year prior to the durable medical equipment (DME) order. The record shows that the Plan 
made several attempts to obtain the necessary documentation without success. Therefore, we decided that the 
Plan does not have to pay for a continuous glucose monitor (CGM) (A4239) provided on July 29, 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 you still require extensive hands on assistance from 
the nursing and therapy staff at the hospital to get out of bed. You also say you will need closer medical 
management of your current medical needs and disease. The Plan denied your request. The Plan says an IRF 
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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
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 therapy and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. 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.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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on August 04, 2023. 
 
You asked the Plan to pay for laboratory services. You say that this service is supported in the records. 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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 laboratory services provided on August 04, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy (PT) services provided on March 27, 2023.

You asked the Plan to pay for these services. You say that you feel that you should not be responsible for
the charges. The Plan denied your request. The Plan says that you have coverage under another Plan that is
responsible for payment review first. Maximus overturned the Plans denial for insufficient information in the
case file. The Plan requested a reopen and provided additional information. The Plan notes that the provider is
a participating provider. The provider is directed on how to appropriately bill enrollees and that in this case
additional information was needed from you to appropriately to process this claim. The Plan continues to
pursue reimbursement from the primary insurer, pursuant to Plan's obligations under Medicare Secondary
Payer rules. The Plan has also directly advised you documentation related to the cancellation of the other
insurance policy is required to be submitted to the Plan. At this point, you have not submitted the required
documentation.

The Plan is correct in this case. The Plan must follow Medicare rules. The rules state that Medicare plans are
considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not
responsible for paying for services until the claim for those services has gone to the primary insurer. However,
plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits
with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for
payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can
pay for the services and submit a bill for reimbursement to the primary insurer.

The Plan has met its obligation with regards to coordination of benefits based on the new information
submitted with the reopen request. As the secondary insurer, the Plan cannot be held responsible for these
services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan
does not have to pay for physical therapy (PT) services provided on March 27, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) for the enrollee.

You asked the Plan to pre-approve a CGM. You say that the patient has early dementia and having a very
difficult time poking her fingers. The Plan denied your request. The Plan says that the enrollee does not meet
criteria for coverage. Maximus overturned the Plan's denial based on medical necessity. The Plan requested a
reopening and states that this was not upheld based on medical necessary but for the fact the enrollee does not
meet Medicare coverage criteria. The Plan is correct in this case. Medicare rules say that therapeutic CGMs are
considered medically reasonable and necessary when prescribed in accordance with their FDA indications for
enrollees with diabetes who are insulin treated or who have a history of problematic hypoglycemia and have
had an in-person visit with their treating physician to evaluate their diabetes control and determine whether the
criteria for coverage have been met. The documentation indicates that the enrollee does not use insulin or have
a history of problematic hypoglycemia. Based on this information, we decided that Medicare rules for coverage
of a CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous
glucose monitor (CGM) for the enrollee.
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 needs this care to regain independence 
before returning home. The Plan denied your request. The Plan says the enrollees medical condition does not 
require IRF services, and care can be provided in another setting.  
 
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 medical, rehabilitation, and nursing needs does not 
require IRF care with an interdisciplinary approach to rehabilitative care. The enrollee's rehabilitation needs 
can be safely provided in an alternate 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 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room services provided on 
June 28, 2023. 
 
You asked the Plan to waive the copayment for the emergency room services. You say that the cost share is 
wrong. 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 $50 
copayment for emergency care. 
 
You have been asked to pay a $50 copayment for the emergency room services. This item/service falls within 
the emergency care 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 emergency room 
services provided on June 28, 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 you have no family to care for you and you need 
intense therapy to learn how to car for yourself. The Plan denied your request. The Plan says admission to the 
IRF 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 review indicates that at this time, you are working with therapy and had not 
attempted to walk as of January 22, 2024. You have declined transferring between surfaces and have required 
maximal assistance from two people to move about in bed. The review has determined that the complexity of 
your nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitation care. You do 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 you 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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee's conditions meet the criteria for an IRF 
admission. The Plan denied your request. The Plan says the enrollee does not meet the requirements 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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical problems are stable, and there are no complex nursing or rehabilitation needs. Medically necessary 
services 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: 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 an IRF admission is the enrollee's best opportunity 
for recovery. The Plan denied your request. The Plan says the services the enrollee needs can be provided 
safely in other settings, for example, a skilled nursing facility, home with home health services or home with 
outpatient therapy.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found 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's 
medical problems are stable and 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 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on July 21, 2023. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this test is not FDA 
approved. 
 
The Plan must follow Medicare rules. Medicare rules say that testing assays must be FDA approved/cleared, or 
if a laboratory developed test (LDT), have a published, peer-reviewed study supporting analytic validity, or 
certification by a third-party consistent with the New York State Department of Healths Clinical Laboratory 
Evaluation Program (CLEP) review standards. 
 
We looked at the file and Medicare rules. The requested Tempus xR testing in this case is not Food and Drug Administration (FDA) approved, and therefore is not covered. Based on this information, we decided that 
Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the genetic testing provided on July 21, 2023.