Persius/hicric huggingface dataset:
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 SNF care is medically necessary and beneficial for 
the enrollee. The Plan denied your request. The Plan says the level of care the enrollee requires could be 
provided in the long-term care setting in which they reside. 
 
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 there are no identifiable skilled nursing service needs. There are identifiable skilled 
therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. This 
enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled 
nursing facility 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous nerve stimulator. 
 
You asked the Plan to pre-approve a percutaneous nerve stimulator. You say that the enrollee has suffered from 
chronic low back pain for several years and have undergone lumbar laminectomies without any pain relief.  
The Plan denied your request. The Plan says a percutaneous nerve stimulator 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 a percutaneous nerve stimulator. Our 
reviewer says that a percutaneous nerve stimulator is not medically necessary. Our physician reviewer found 
that a percutaneous nerve stimulator is considered experimental for use as a treatment for chronic pain, and 
more research is needed. 
 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 percutaneous nerve stimulator have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a percutaneous nerve stimulator.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergent ambulance transport to a physician office 
on August 1, 2023. 
 You asked the Plan to pay for the non-emergent ambulance transport . You say that the enrollee has non-
emergency benefits for ambulance if it meets criteria.  The Plan denied your request. The Plan says ambulance 
transport to or from an outpatient office or facility for a scheduled appointment is not a Medicare covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when 
they meet certain origin and destination requirements. A doctors office is not a covered destination.  
 
The services you have asked the Plan to pay for are ambulance transport services to a doctors office. 
Therefore, we decided that the Plan does not have to pay for the non-emergent ambulance transport to a 
physician office on August 1, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ambulance service with no transport. 
 
You asked the Plan to pay for an ambulance without transport. You say that you fell and could not get up. Your 
wife could not lift you and had to call an ambulance. The Plan denied your request. The Plan says an 
ambulance benefit is a transport benefit. Without transportation, there is no coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on August 16, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for an ambulance service with no transport.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shoe insert (L3450). 
 
You asked the Plan to pre-approve the shoe insert. You say that this device is medically necessary. The Plan 
denied your request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. Medicare rules say that inserts and other shoe modifications (L3450) are 
covered if they are on a shoe that is an integral part of a covered brace and if they are medically necessary for 
the proper functioning of the brace. 
 
We looked at the file and Medicare rules. The requested insert is not part of a brace. Based on this information, 
we decided that Medicare rules for coverage of the shoe insert have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a shoe insert (L3450).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on September 25, 2023, billed 
with codes 81433. 
 
You asked the Plan to pay for the genetic testing billed. You say that based on the above information and the 
physician's decision to order the test, you are requesting coverage at this time for the claim. The Plan denied 
your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
September 25, 2023, billed with codes 81433.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for continued physical therapy (PT) services.

You asked the Plan to provide coverage for continued the requested therapy services. You say that at the time
of the appeal, this therapy was medically necessary. The Plan denied your request. The Plan says 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 at the time of the
appeal, you had been in therapy for 10 months and had plateaued. At that point any further treatment would be
maintenance which is not covered by Medicare.

The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that Medicare pays for
medically necessary outpatient therapy. Maintenance therapy is not covered. Based on the medical records
provided, your condition had plateaued, and you were not expected to make further progress. Any treatment
after beyond this would be considered maintenance which is not covered by Medicare. The required criteria for
coverage were no longer met. Therefore, we decided that the Plan does not have to provide coverage for
continued physical therapy (PT) services.
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 
August 11, 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 relevant medical records which support medical 
necessity for the supplies provided in this case. There is no history of problematic hypoglycemia recorded 
within the documentation. In addition, the records do not indicate that the member is seen every 6 months to 
document adherence to their CGM regimen and diabetes treatment plan. 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 August 11, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided without transport to the 
hospital on April 27, 2023. 
 
You asked the Plan to pay for the ambulance services. You say that you feel that you are not responsible for the 
bill because you were told by the provider that you did not have to go to the hospital if you were feeling better. 
The Plan denied your request. The Plan says that a medical transport was not provided because you refused 
transport to the hospital. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on April 27, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided without transport 
to the hospital on April 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided from July 7, 2022, to September
6, 2022, by an out-of-network (OON) provider.

You asked the Plan to pay for the dental services. You say that you would like to be reimbursed for these
services because the provider does not accept your insurance plan. The Plan denied your request. The Plan says
that the services are not covered benefits and were rendered by a non-contracted provider. Maximus overturned
the Plan's denial based on lack of information. The Plan requested a reopening and stated that these services
are not covered out-of-network and you were not given prior authorization for these services. The Plan is
correct in this case. The Plan has now included the relevant EOC to confirm you do not have out-of-network
benefits for non-emergency situations.

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 dental services provided from July 7, 2022, to September 6, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the SPRINT peripheral nerve stimulator. 
 
You asked the Plan to pre-approve the stimulator. You say that this is medically necessary. The Plan denied 
your request. The Plan says a technology assessment for this specific equipment says that there is very little 
medical literature and information that shows this system is helpful and safe. 
 
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 stimulator. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the SPRINT device is experimental for the treatment of chronic pain conditions. More 
research is needed. 
 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 stimulator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the SPRINT peripheral nerve stimulator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 26, 2023. 
 
You asked the Plan to pay for an office visit. You say that this 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 an office visit provided on September 26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on September 08, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that this testing was medically necessary. 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 laboratory services provided on September 08, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair.  
 
You asked the Plan to pre-approve a shower chair. You say that the requested shower chair is medically 
necessary and will help you from falling again. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Leqvio 
 
You asked the Plan to pre-approve Leqvio. You say that the enrollee is unable to tolerate any of the other 
drugs. The Plan denied your request. The Plan says drugs are only covered under the medical benefit if they are 
administered by a doctor and are being supplied directly from a doctors office, or they are delivered to the 
doctor by a pharmacy who bills the doctor.  
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Leqvio
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on October 09, 2023. 
 
You asked the Plan to pay for the office visit. You say that the services were medically necessary. 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 office visit provided on October 09, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive hereditary pharmacogenomic testing and 
hereditary genetic cardiac testing performed on June 13, 2023. 
 
You asked the Plan to pay for the testing. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no documentation from the provider documenting the drugs being considered for 
use, and no documentation to how the results will impact treatment. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the review indicates that there is no documentation from the provider documenting the drugs being 
considered for use, and no documentation to how the results will impact treatment. The review has determined 
that the enrollee does not meet the criteria for both of these tests. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for comprehensive hereditary pharmacogenomic testing and hereditary genetic cardiac testing performed 
on June 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 9, 2022. 
 
You asked the Plan to pay for the office visit. You say that the claim should be paid as billed. The Plan denied 
your request. The Plan says Medicare doesn't cover services for Veteran Affairs hospitals, medical centers, or 
administration hospitals. 
 The Plan must follow Medicare rules. The rules say that VA facilities and military hospitals are excluded from 
participating in Medicare. The rules also 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 an office visit provided on September 9, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

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

 
We decided that the Plan does not have to issue reimbursement for the adjunctive pre-diagnostic test that aids 
in the detection of mucosal abnormalities (D0431) provided on October 2, 2023. 
 
You asked the Plan to issue reimbursement for this service. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says this service is not covered under 
the supplemental dental policy.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the service provided is not among 
those covered under this benefit.  
  
 
Therefore, we decided that the Plan does not have to issue reimbursement for the adjunctive pre-diagnostic test 
that aids in the detection of mucosal abnormalities (D0431) provided on October 2, 2023.