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

We decided that the Plan does not have to pay for to pay for an ultrasound of the heart with color-depicted
blood flow, rate, direction, and valve function (93306) provided to the enrollee on January 02, 2023.
You asked the Plan to pay this claim. The Plan denied your request. The Plan says the diagnosis codes reported
are not among those listed as approved for coverage of this service. Maximus overturned the Plans denial. The
Plan requested a reopen and stated that the diagnosis codes billed, M25.50 and M35.9 are not listed as covered
diagnosis codes in LCA A56781 for code 93306.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. In this case, the diagnosis codes reported are not listed as a covered for code 93306.
Medicare rules for coverage of this claim have not been met. Therefore, we decided that the Plan does not have
to pay for to pay for an ultrasound of the heart with color-depicted blood flow, rate, direction, and valve
function (93306) provided to the enrollee on January 02, 2023.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab testing services provided on August 25, 2022.
You asked the Plan to pay for the lab testing services. You say that the testing was done in the enrollee's best
interest. The Plan denied your request. The Plan says that the testing will not directly impact clinical
management. Maximus overturned the Plan's denial. The Plan requested a reopening and stated that the records
did not show the enrollee met criteria for coverage.
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.
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 lab testing services have been met.
Sufficient medical records were not submitted to show the enrollee meets criteria for coverage of these
services. Therefore, we decided that the Plan does not have to pay for the lab testing services provided on
August 25, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need this care. The Plan denied your request. 
The Plan says medical records do not support the need for an IRF admission and, your needs can be provided at 
another level of care. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found your condition is in fact complex and tenuous. There is every reason to expect that you will participate in 
and benefit from services including physical therapy and occupational therapy. You will also benefit from 
physician oversight of poly- pharmacy, and case manager coordination of any additional services that might be 
needed to make your home environment sustainable as well as avoid preventable admissions to the acute 
hospital. Therefore, the requested inpatient rehabilitation facility admission is approved. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for a complete ultrasound of abdomen and pelvis artery and vein
blood flow (93975) provided on January 6, 2023.
You asked the Plan to pay for this claim. You say that these services should be paid by the Plan. The Plan
denied your request. The Plan says the Medicare billing criteria are not met. Maximus overturned the Plans
denial. The Plan requested a reopen and noted that the provider billed with diagnosis codes of R634, R194,
R42, R531 and Z7901. These diagnosis codes do not fall under the coding and billing requirements listed in
LCA A56758.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. In this case, the diagnosis codes reported are not listed among those that are covered
for this service. Medicare rules for coverage of this claim have not been met. Therefore, we decided that the
Plan does not have to pay for a complete ultrasound of abdomen and pelvis artery and vein blood flow
(93975) provided on January 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for an epidural steroid injection for the enrollee.
You asked the Plan to provide coverage for an ESI injection for the enrollee. You say that at the time of the
appeal, this treatment 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 noted
that Maximus did not apply the correct criteria. The Plan stated the enrollee did not meet the requirement of
participating in physical therapy or a home exercise program and the medical records reflect this.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules require enrollees
participate in a rehabilitative program such as home exercise or physical therapy prior to and in conjunction
with treatment with this injection. The medical records do not show the enrollee was participating in this type
of therapy or exercise when approval for this treatment was requested. Medicare rules for this type of injection
were not fully met. Therefore, we decided that the Plan does not have to provide coverage for an epidural
steroid injection for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton treatment. 
 
You asked the Plan to pre-approve proton treatment. You say that it is medically necessary. The Plan denied 
your request. The Plan says the enrollee does not meet the requirements for approval. 
 
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 proton treatment. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that proton therapy is generally not needed, particularly when not supported by a 
dosimetric rationale. It is unfavorable due to lack of demonstration of need and proton therapy not being 
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 proton treatment have not been met. Therefore, we decided that the Plan does 
not have to pre-approve proton treatment.
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 need this care to perform everyday skills. The 
Plan denied your request. The Plan says medical records do not support the need for an IRF admission and, 
your needs can be provided at 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 your medical, rehabilitation, and nursing needs do not require IRF 
care with an interdisciplinary approach to rehabilitative care. While the medical record supports a need for 
physical or occupational therapy, there is no documented need for intensive rehabilitation services.  
 
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 provide coverage for skilled nursing facility (SNF) services.
You asked the Plan to provide coverage for SNF services . You say that at the time of the appeal, SNF services
were medically necessary. The Plan denied your request. The Plan says at the time of the appeal, you had
exhausted the 100-day benefit. Maximus overturned the Plans denial because documentation of previous days
used was not provided in the case file. The Plan requested a reopen and provided the required documentation.
The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that enrollees are covered
for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a
hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient
hospital or SNF care.
The file shows that you received 100 days of SNF care during the benefit as follows:
October 1, 2022 through October 7, 2022, for 7 days
October 27, 2022 through November 20, 2022 for 25 days
December 11, 2022 through December 23, 2022 for 13 days
January 27, 2023 through February 16, 2023 for 21 days
March 13, 2023 through April 15, 2023 for 48 days.
The total is 114 covered days, which exceeds the number of days required to be covered by the Plan. Although
you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during
this benefit period. You will be eligible for a new benefit period when you have not been receiving care in a
hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the Plan does not have
to provide coverage for skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 power wheelchair (K0823). 
 
You asked the Plan to pre-approve Group 2 power wheelchair. You say that you cannot move around the home 
in a regular wheelchair. The Plan denied your request. The Plan says the records do not show that you are 
unable to complete mobility-related activities of daily living (MRADLs) in the home, that you are unable to 
safely use a scooter, or that this wheelchair will fit in your home. 
 
The Plan follows Medicare rules. Medicare rules state that a K0823 Group 2 power wheelchair will be covered 
if specified criteria are met. 
 
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 Group 2 power wheelchair. Our 
reviewer says that you do not meet criteria for a Group 2 power wheelchair. Our physician reviewer found the 
documentation indicates that you have a mobility deficit but is not specific on how this affects various 
MRADLs in the home. The documentation does not include a gait assessment, assessment of your attempts at 
using a manual wheelchair or walker, evaluation of your upper extremities, or home assessment supporting that 
a Group 2 power wheelchair can safely maneuver in your home. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Group 2 power wheelchair have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Group 2 power wheelchair (K0823).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet the criteria for admission. 
 
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 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 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 skilled therapy on an inpatient basis in a skilled nursing 
facility (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 skilled nursing facility (SNF) care.
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 the LTACH services. You say that the enrollee needs the LTACH services 
to promote optimal recovery and regain maximum function. The Plan denied your request. The Plan says the 
enrollee can receive the required services at a lower level of care. 
 
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 that the enrollee is receiving appropriate care in the current acute care setting as 
provided by the health Plan. The documentation does not support that LTACH services are medically 
appropriate at this time. 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 LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits to be provided by an out-of-network (OON) 
provider.  
 
You asked the Plan to pre-approve the office visits. You say that you wish to remain with the provider you 
have been with for several years. The Plan denied your request. The Plan says that they approved 3 visits with 
your preferred doctor in order to give you time to choose an in-network provider.  
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
office visits to be provided by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided the Plan does not have to provide coverage for continued skilled nursing facility (SNF) care
beyond July 2, 2023.
You asked the Plan to provide coverage for continued SNF care. The Plan denied your request. The Plan says
continued SNF care was no longer required. Maximus overturned the Plans denial because the case file lacked
a valid Notice of Non-Coverage. The Plan requested a reopen and submitted the required document.
The Plan is correct in this case. 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.
Based on the medical records provided, as of July 2, 2023, you no longer required skilled nursing or skilled
therapy services on a daily basis at an inpatient facility level of care. Therefore, we decided that the Plan does
not have to provide coverage for continued skilled nursing facility (SNF) care beyond July 2, 2023.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a duplex scan of extracranial arteries; complete bilateral
study (93880) provided to the enrollee on November 30, 2022.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says the diagnosis code reported, Z98.890, is on the list of codes for coverage for this service.
Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the
correct LCA criteria.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. In this case, the LCA A56758 shows the accepted diagnosis codes are Z09, Z48.812
and Z86.73. The diagnosis code reported, Z98.890, is not among those listed as a covered diagnosis. Medicare
rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to
pay for a duplex scan of extracranial arteries; complete bilateral study (93880) provided to the enrollee on
November 30, 2022, and billed under diagnosis code Z98.890.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 1 standard power operated vehicle (K0800).  
 
You asked the Plan to pre-approve a group 1 standard power operated vehicle. You say that the enrollee's 
physical therapist recommended the scooter, and you would like this denial to be reconsidered.  The Plan 
denied your request. The Plan says the purchase of a motorized scooter is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 
 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 group 1 standard power operated 
vehicle. Our reviewer says that the enrollee does not meet the criteria for coverage. Our physician reviewer 
found the enrollee has chronic back pain which limits their mobility to 75 to 100 feet. The enrollee does not 
require the device to complete self-care in the home. Our reviewer also fund that the enrollee is able to walk 
household distances. 
 
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 group 1 standard power operated vehicle have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a group 1 standard power operated vehicle (K0800).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). You asked the Plan to pre-approve the CGM. You say that the enrollee needs it to monitor their glucose levels. 
The Plan denied your request. The Plan says the Medicare criteria was not met. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the CGM. Our reviewer says that the 
CGM coverage criteria was not met. Our physician reviewer found that the coverage criteria for a CGM 
requires insulin use or low blood sugars. This enrollee is on 1 medication for diabetes mellitus, and it should 
not cause low blood sugars. We are not told of any low blood sugars. Hence although the CGM may help the 
enrollee, coverage criteria for the CGM are not met at this time. 
 
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 CGM have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continuous glucose monitor (CGM).