Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing billed for date of service July 26, 2023. 
 
You asked the Plan to pay for the billed testing. The Plan denied your request. The Plan says one code must be 
submitted for the panel. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
 The file shows that the fungal panel test was billed using codes 87801, 87798, and 87481. We looked at the file 
and Medicare rules. The documentation supports that this panel used the nucleic acid probe technique. There is 
no evidence that multiple procedures, multiple methodologies, or multiple kits were used in this case. As such, 
a single code with one unit of service should be used. Based on this information, we decided that Medicare 
rules for coverage of the testing panel have not been met. Therefore, we decided that the Plan does not have to 
pay for the panel testing billed for date of service July 26, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health physical therapy and home health 
occupational therapy. 
 You asked the Plan to pre-approve home health services. You say that this is medically necessary. 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 
does not have documented skilled therapy needs. The enrollee appears to be at her baseline level of function. 
 
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 home health physical therapy and home health occupational therapy.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the paramedic intercept services provided on September 20, 
2023. 
 You asked the Plan to pay for the paramedic intercept services. You say that you are appealing the denial of the 
paramedic intercept as you had no control over this. The Plan denied your request. The Plan says the 
requirements for a paramedic intercept have not been met. 
 
The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by 
an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. 
Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as 
defined above. It is noted that the only State in which these criteria are met is New York. 
 
The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural 
according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for the 
paramedic intercept services provided on September 20, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve the home ventilator. You say that the enrollee is at high risk for costly 
hospital re-admissions and potentially life-threatening exacerbations.  The Plan denied your request. The Plan 
says a home ventilator is not medically necessary for the enrollee because their needs can be met with an 
alternative device such as a BiPAP device with average volume-assured pressure support (AVAPS).  
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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 home ventilator. Our reviewer says 
that the home ventilator is not medically necessary. Our physician reviewer found the enrollee has COPD, 
interstitial lung disease, obstructive sleep apnea, bronchiectasis, chronic cough, and chronic aspiration. An 
arterial blood gas on January 4, 2024 showed a normal pH and PaC02. There are no pulmonary function tests to 
document airways obstruction and assess severity. There is no diagnosis of thoracic restrictive disease or 
neuromuscular disease. The enrollee does not have chronic CO2 retention, and therefore does not qualify for a 
respiratory assist device or a home ventilator. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy services provided on December 8, 2022, 
through January 30, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the physical therapy services. The Plan denied your request. The Plan says 
Medicare rules say that health plans can require enrollees to get care from network physicians. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan must 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 could provide 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/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 physical therapy 
services provided on December 8, 2022, through January 30, 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 anesthesia services described by codes 99100 and 00731 billed for date of service April 6, 2022.

You asked the Plan to pay for 99100 and 00731. You say that 99100 and 00731 should be paid as billed because they are supported in the medical record. The Plan denied your request. The Plan says 99100 is denied because it is considered bundled and not separately payable. 00731 is denied because the POS billed is inconsistent with other claims submitted for this enrollee.

The Plan must follow Medicare rules. Medicare rules say that the Physician Fee Schedule Status Indicator B means that payment for covered services is always bundled into payment for other services not specified. The rules also say that when services are rendered for an enrollee who is a registered inpatient of a hospital, the correct POS code, regardless of where any face-to-face service occurs, is that of the appropriate inpatient POS code (at minimum POS 21). 

We looked at the file and Medicare rules. Regarding code 99100, we find that this procedure code has a status indicator of B on the Physician Fee Schedule. This means that procedure code 99100 is not separately payable. Regarding code 00731, we have confirmed that the claim for this service was billed with POS 22, indicating an on-campus outpatient hospital. The case file also contains evidence that the enrollee was a registered inpatient of the hospital on the date of service in question, April 6, 2022. Per Medicare rules, when an enrollee is an inpatient at a hospital, the correct place of service, regardless of where any face-to-face encounters took place is the appropriate inpatient POS code (at a minimum POS code 21). As such, the denials of 99100 and 00731 are appropriate. Based on this information, we decided that Medicare rules for coverage of 99100 and 00731 have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services described by codes 99100 and 00731 billed for date of service April 6, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF)
admission and services for the enrollee.

You asked the Plan to provide coverage for IRF care. You say that at the time of the appeal, IRF admission was
medically necessary. The Plan denied your request. The Plan says 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 the medical records show the enrollee was limited by the new left below
the knee leg and right great toe amputations as well as the weakness, fatigue, poor standing tolerance, and
problems following commands. The enrollee also required a mechanical lift for standing and to move to a
chair.

The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that IRF admission is
covered only when it is medically reasonable and necessary as described in the Medicare rules section. The
medical records provided do not show that at the time of the appeal the enrollee had the ability to participate in
the type of intensive therapy provided by an IRF. Medicare coverage criteria were not met. Therefore, we
decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF)
admission and services for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PET scan.  
 
You asked the Plan to pre-approve the PET scan. You say that you have dementia and other complications. The 
Plan denied your request. The Plan says a PET scan is not medically necessary.  
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that a 
PET scan is not medically necessary. Our physician reviewer found that you are suspected to have both 
vascular dementia and a neurodegenerative process. However, you are noted to meet the diagnostic criteria for 
either AD or FTD. 
 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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a PET scan.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled nursing (G0299 x4), home health 
physical therapy (G0151 x8), and home health speech therapy (G0153 x4). 
 You asked the Plan to pre-approve home health services. You say that this is medically necessary. 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 
does not have documented home health needs. The enrollee appears to be functioning at a level commiserate 
with 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health skilled nursing (G0299 x4), home health physical therapy (G0151 
x8), and home health speech therapy (G0153 x4).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided from September 7, 
2023, through September 14, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the skilled nursing services. The Plan denied your request. The Plan says 
unauthorized non-emergent care outside of the plan is not a covered benefit. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan must 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/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 skilled nursing services provided from September 7, 2023, through September 14, 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 subsequent nursing facility care services provided on 
February 13, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the subsequent nursing facility care services. You say that the services provided 
were medically necessary. The Plan denied your request. The Plan says the services were not authorized. 
 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/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 subsequent nursing facility care services provided on February 13, 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 direct skilled nursing services provided on July 3, 2023, to 
September 11, 2023. 
 
You asked the Plan to pay for direct skilled nursing services. You say that you are requesting reconsideration 
for the denied claim. The Plan denied your request. The Plan says the facility must be enrolled to participate in 
the Medicare program. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for direct skilled nursing services provided 
on July 3, 2023, to September 11, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vivaer procedure.  
 
You asked the Plan to pre-approve the Vivaer procedure. The Plan denied your request. The Plan says the 
Vivaer procedure is 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 the Vivaer procedure. Our reviewer 
says that the Vivaer procedure is not medically necessary. Our physician reviewer found that the enrollee has 
nasal obstruction. However, there is insufficient literature to support the safety and efficacy of the requested 
service for the enrollee's specific conditions. The records do not establish the medical necessity and 
reasonableness, as defined by Medicare rules, of the requested service. Therefore, the elements of the coverage 
criteria are not satisfied, and the requested service is not 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 Vivaer procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vivaer procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that you need this device due to the alert and alarm 
features. You say that you have hypoglycemic unawareness and rely on the alarms. You also say that you 
cannot test your blood sugar manually due to vision impairment. The Plan denied your request. The Plan says 
only the preferred brand products listed in the EOC are covered.  
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including non-preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for the CGM. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 continuous 
glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a FreeStyle Libre 3 Sensor.

You asked the Plan to provide coverage for this sensor. You say that 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 request is only for the
sensor, which is being used with a smart device, and not with the DME-eligible CGM system and therefore is
not covered.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare has specific coverage
requirements for this type of equipment. Medicare does not cover equipment for convenience.

As this sensor is requested specifically for use with a cell phone for convenient numbers check, it is not eligible
for coverage. Therefore, we decided that the Plan does not have to provide coverage for a FreeStyle Libre 3
Sensor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office visit to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve the office visit. You say that you were told that the network provider does 
not offer vision therapy services. You say you want to service approved to help correct your eye issues. The 
Plan denied your request. The Plan says the provider is out-of-network. 
 
 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 Plan has network providers available who are capable of providing the office visit in this appeal. (Please 
note, items and services received in-network are still subject to any other Medicare coverage rules that apply.) 
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 visit to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for a second claim for services provided to the enrollee on
January 13, 2023, and billed under codes 96401 and J2356.

You submitted a second claim for these services for payment. The Plan denied your request. The Plan says this
claim is a duplicate of a previously paid claim and was correctly denied. Maximus overturned the Plans denial
for insufficient claim information in the case file. The Plan requested a reopen and provided additional claim

information.
The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that claims or claim lines
that have been determined to be exact duplicates of another claim or claim line are denied. We looked at the
claims submitted by the Plan. There is evidence the Plan previously paid these services. There are no medical
records provided to show this was a separate and distinct service from those previously paid. Based on this
information, we decided that the Medicare rules for payment of the second claim have not been met. Therefore,
we decided that the Plan does not have to pay for a second claim for services provided to the enrollee on
January 13, 2023, and billed under codes 96401 and J2356.