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

We decided that the Plan does not have to pay for the peripheral nerve block (64445) provided to the enrollee
on March 1, 2023.

You asked the Plan to pay for the peripheral nerve block. You say that this should be paid for The Plan denied
your request. The Plan says that this was not billed with an appropriate diagnosis code. Maximus overturned
the Plan's denial based on medical necessity. The Plan requested a reopening and stated that this was not
upheld based on medical necessity but because it was not billed correctly. The Plan is correct in this case.
Medicare rules state that coverage for CTP code 64445 is limited to certain diagnoses. The diagnosis coded
provided is G54.6. CPT 64445 is not covered with this diagnosis code. Therefore, we decided that the Plan
does not have to pay for the peripheral nerve block (64445) provided to the enrollee on March 1, 2023.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the prostate cancer screening provided on August 3, 2022.

You asked the Plan to pay for the prostate cancer screening. You say that this service was medically necessary
and appropriate. The Plan denied your request. The Plan says that your benefit for the requested item or service
has already been exhausted. Maximus overturned the Plan's denial because of a lack of information. The Plan
requested a reopening and stated that this benefit has been exhausted. The Plan is correct in this case. The Plan
has provided your Explanation of Benefits indicating they covered a PSA test for you on February 17, 2022.
Your contract with the Plan clearly says that PSA tests are covered once every 12 months. This means that the
Plan correctly covered one PSA test and a second test cannot be paid for until 12 months has passed. Therefore,
we decided that the Plan does not have to pay for the prostate cancer screening provided on August 3, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for additional units of code 88341 billed to the enrollee for
November 17, 2022.

You asked the Plan to pay this claim. The Plan denied your request. The Plan says the Medicare billing criteria
were not met. Maximus overturned the Plans denial for medical necessity. The Plan requested a reopen and
noted that the Plan is not disputing that additional units were in fact rendered, but that the medical record
documentation does not support the additional units billed. The Plan notes the provider also did not give a
medical necessity reason for why additional units were needed. The Plan provided documentation to show the
NCC Policy Manual Chapter 1 Section V very clearly outlines this requirement.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that the provider,
supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to
determine whether payment is due and the amount of payment.

Based on the medical records provided, there is insufficient explanation in the record to determine if Medicare
rules for coverage of the additional units billed were met. Therefore, we decided that the Plan does not have to
pay for additional units of code 88341 billed to the enrollee for November 17, 2022.
Appeal type: Practitioner Services
Decision: Partially Favorable

 We decided that the Plan has to pre-approve 1 unit of 77280. We decided that the Plan does not have to pre-approve the rest of the units of 77280, and 77290. 

You asked the Plan to pre-approve a complex simulation (77290) and daily simple (77280) simulations (each using ultrasound guidance). You say that this is medically necessary. The Plan says that this treatment is considered experimental/investigational and is not medically necessary.

We decided that the Plan has to pre-approve 1 unit of 77280. 

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 for 77280. Our reviewer says that this is needed prior to the first treatment, since initial simulation would be simple in this case. If billed on the 1st day of treatment, this code would supersede the billing for treatment on that day.

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 item/service at issue have been met. Therefore, we decided that the Plan has to pre-approve 1 unit of 77280. 

We also decided that the Plan does not have to pre-approve the rest of the units of 77280, and 77290.

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 for 77290 and the rest of the requested units of 77280. Our reviewer says that billing for this is not supported by the case records, as an ultrasound to determine depth and size of target would more appropriately be done as a simple vs complex simulation. Additionally, the billing for daily simple simulations would not be "furnished in accordance with accepted standards of medical practice."

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 item/service at issue have not been met. Therefore, we decided that the Plan does not have to pre-approve the rest of the units of 77280, and 77290.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that these services are necessary for the enrollee to regain 
their independence. The Plan denied your request. The Plan says the required services can be provided in an 
alternate 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 nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. There are no 
complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies. 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: 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 these services are medically necessary for the 
enrollee. The Plan denied your request. The Plan says the required services can be provided in an alternate 
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 nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. There are no 
complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies. 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that  the requested SNF admission is medically 
necessary. The Plan denied your request. The Plan says the records do not show a need for daily skilled 
services that can only be provided at a skilled nursing facility after physical therapy testing.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device 
(HFCWOD). 
 
You asked the Plan to pre-approve a HFCWOD. You say that the item is medically necessary. The Plan denied 
your request. The Plan says the item is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.  
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a HFCWOD. Our reviewer says that the 
item is not medically necessary. Our physician reviewer found the patient is described as being too frail for 
chest percussion therapy, but there is no mention of other clearance measures, such as the flutter valve.  There 
is no diagnosis of cystic fibrosis or neuromuscular disease.  Medicare requires that other clearance measures, 
such as the flutter valve, be tried prior to considering the chest wall oscillation device. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a HFCWOD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a high frequency chest wall oscillation device (HFCWOD).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator system. 
 
You asked the Plan to pre-approve a home ventilator system. You say that the enrollee needs a home ventilator 
to regain full functionality for everyday living. The Plan denied your request. The Plan says a home ventilator 
is not medically necessary for this patient 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 a home ventilator system. Our reviewer 
says that a home ventilator system is not medically necessary. Our physician reviewer found that the enrollee 
has COPD and was recently hospitalized with an exacerbation. While the arterial blood gas was consistent with 
acute chronic hypercarbic respiratory failure, there is no diagnosis of thoracic restrictive disease or 
neuromuscular disease. The enrollee has improved with a standard BiPAP and may benefit from a BiPAP with 
AVAPS during sleep as an outpatient which has not been tried and failed. Therefore, a home ventilator 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 a home ventilator system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a home ventilator system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture services provided on August 1, 2023, to 
August 8, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the acupuncture services. You say that you searched a list of network providers, 
and you chose this provider from the list. The Plan denied your request. The Plan says the provider was out-of-
network, and the services are not covered benefits. 
 
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 did not pre-approve the 
acupuncture services. We found no exception that would require the Plan to pay for the acupuncture services. 
Therefore, we decided that the Plan does not have to pay for the acupuncture services provided on August 1, 
2023, to August 8, 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 LTACH services. 
 
You asked the Plan to pre-approve LTACH services. You say that the enrollee needs LTACH services as the 
local skilled nursing facilities are not able to manage her mechanical ventilation, telemetry monitoring, and risk 
for as needed hemodialysis. The Plan denied your request. The Plan says the enrollee does not meet the 
requirements for an LTACH admission. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found based on the documentation provided, there is no evidence that the enrollee requires 
services that are not already available at the current facility. As LTACHs and acute care hospitals are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee 
can remain at the current acute care facility until such time as no acute services are required.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of LTACH services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral device (E0486) purchased on July 13, 2023. 
 
You asked the Plan to pay for the oral device. You say that this should be covered. The Plan denied your 
request. The Plan says the item was obtained through a provider that is not certified with Medicare. 
 
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 the oral device (E0486) purchased on 
July 13, 2023.
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 medical records provided support the 
need for the requested LTACH admission.  The Plan denied your request. The Plan says based on Medicare 
guidelines and the information we have about the enrollee's condition they do meet all of the requirements.  
 
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 record indicates that the enrollee has ongoing acute medical issues that still 
requires acute care services. The medical record does not indicate that the enrollee requires services that are not 
currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are 
not satisfied. 
 
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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that treatment of the enrollee's complex 
medical needs clearly meets the standards under Centers for Medicare and Medicaid Services. The Plan denied 
your request. The Plan says  based on Medicare guidelines, the LTACH services requested do not meet the 
requirements for approval.  
 
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 was admitted for below knee amputation in the setting of non-re-
constructable peripheral vascular disease with tissue necrosis.  The record indicates that the enrollee has ongoing acute medical issues that still requires acute care services. 
The medical record does not indicate that the enrollee requires services that are not currently receiving but that 
would be available at the LTACH facility. The elements of the coverage rules are not satisfied. 
 
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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that admission to the LTACH is a medical 
necessity.  The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute 
care and is currently unstable for transfer to an 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 is currently undergoing treatment at the acute care hospital for an 
acute stroke and multiple chronic wounds/infections. The enrollee is not intubated/ventilated. There is no 
evidence that the enrollee requires services that are not currently available. The enrollee can remain at the 
current acute care hospital until such time no acute services are required. The enrollee can then be 
transferred/discharged to a lower level of care for any ongoing long term acute needs. 
 
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.