Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for an E2311 electronic accessory.
You asked the Plan to provide coverage for an E2311 electronic accessory. You say that at the time of the appeal, this electronic accessory was medically necessary for the enrollee. The Plan denied your request. The Plan says while the requested power wheelchair and Medicare approved accessories were covered, the E2311 connection is not medically necessary. 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 expandable controller with harness (E2311) is only necessary if the enrollee needs to control all the power options with the joystick. It should be noted that it is not easier to control the power options with the joystick. It adds a layer of complexity to control both the motion of wheelchair and the power options with the joystick. It is easier to control the power options with separate switches that comes standard with the power option installation. The expandable controller with harness (E2311) is not needed for the operation of the wheelchair base. The expandable controller with harness (E2311) is only needed if the enrollee cannot flip switches to operate the requested power option of tilt and elevation leg rest. The medical records show the enrollee has normal function of wrist and hands and can maintain hand grasp. Therefore, the enrollee would have no trouble activating switches to control the power options and show no medical need for a joystick.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.
The medical records do not show there is an inability on the part of the enrollee to operate the switches that come with the power wheelchair approved versus using a joystick. Medical necessity was not established. Therefore, we decided that the Plan does not have to provide coverage for E2311 electronic accessory.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance transport, inpatient hospital services and behavioral health services provided from August 27, 2022, to September 8, 2022.
You asked the Plan to pay for these services under your Medicare benefit. You say that these services should be covered by the Plan.
The Plan says these services must be addressed under your Medicaid benefit. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan says that this claim denied under your Medicare benefit because you are Medicaid eligible. The Plan included documentation to show that you are Medicaid eligible. The Plan says that Medicare pays covered dually eligible beneficiaries' medical services first, because Medicaid is generally the payer of last resort. Medicaid may cover medical costs that Medicare may not cover or partially covers (such as nursing home care, personal care, and home- and community-based services). These services qualified under the Medicaid coverage.
The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing and coverage information. Your contract states dual eligible enrollees will have services that are covered by either Medicare or Medicaid, but not by both. The services provided fall under your Medicaid coverage and not your Medicare coverage. The IRE does not have jurisdiction over your Medicaid benefits.
Therefore, we decided that the Plan does not have to pay for ambulance transport, inpatient hospital services and behavioral health services provided from August 27, 2022, to September 8, 2022 under your Medicare benefit.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a dual-energy x-ray absorptiometry (DXA), bone density study provided to the enrollee on June 8, 2022.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and demonstrated that this claim denied because the provider billed an inappropriate diagnosis code Z13.820 (Encounter for screening for osteoporosis). The records provided do not show the required criteria were met.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate diagnosis codes. In this case, the records provided do not support the diagnosis code billed. Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for a dual-energy x-ray absorptiometry (DXA), bone density study provided to the enrollee on June 8, 2022.
Appeal type: Transportation
Decision: Unfavorable

We decided the Plan does not have to pay for ambulance services provided to the enrollee on August 11, 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 Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional claim information. The Plan demonstrated that this claim denied because the enrollee was recorded as inpatient status during the date of service. The claim was billed with Modifier HH to show the enrollee was being transported from one hospital to another. The claims history shows the enrollee received emergency care from hospital A from August 10, 2022, to August 11, 2022. The enrollee was picked up from the facility. The enrollee was then transported to hospital B was admitted until August 12, 2022. This was a facility-to-facility transport.
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, this claim should be submitted to the originating hospital who facilitated the transfer for the enrollee from one facility to another. Therefore, we decided that the Plan does not have to pay for ambulance services provided to the enrollee on August 11, 2022, under claim.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided the Plan does not have to pay for a spring powered device (A4258) provided on June 5, 2022.
You asked the Plan to pay for this item. You say that this claim should be paid. The Plan denied your request. The Plan says while this claim was partially paid, code A4258 was paid on a previous claim. Maximus overturned the Plans denial for lack of proof of previous payment. The Plan requested a reopen and provided the missing claim show this item was previously paid by the Plan.
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 Plan has shown this item was already paid for by the Plan. Medicare rules for coverage of this item have not been met. Therefore, we decided that the Plan does not have to pay for a spring powered device (A4258) provided to the enrollee on June 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aid fitting/checking (V5011), hearing aids (V5261), ear mold/insert (V5264), and dispensing fee (V5160) provided on April 13, 2022.
You asked the Plan to pay for out of network hearing services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says the hearing aid fitting out of network is not a covered benefit. Maximus partially overturned the Plans denial. The Plan requested a reopen and noted that these services were not provided by an authorized plan provider and therefore, per your contract, are not covered.
The Plan is correct in this case. Medicare does not pay for hearing aids or related services. The Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids and hearing services provided by a network hearing provider. The Plan has shown these services were not rendered by an authorized hearing provider. Therefore, we decided that the Plan does not have to pay for to pay for the hearing aid fitting/checking (V5011), hearing aids (V5261), ear mold/insert (V5264), and dispensing fee (V5160) provided on April 13, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for inpatient hospital services provided to the enrollee on June 27, 2021, at the Diagnosis Related Group (DRG) originally billed.
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that these services were billed correctly. The Plan denied your request. The Plan says that that the billed DRG is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. Our Medical director looked at the case file and the reopen request. At issue is payment for inpatient hospital services at the DRG originally billed. In this case, you billed the inpatient services provided with principal diagnosis code, G92, defined as Toxic encephalopathy. Our Medical Director states that Toxic encephalopathy describes acute mental status alteration due to medications, illicit drugs, or toxic chemicals. The available clinical documentation supports the use of code G92 (Toxic encephalopathy), and DRG 091 (Other disorders of nervous system with major complication or comorbidity). Our physician reviewer found that the enrollee's condition met Medicare criteria for the inpatient hospital services provided on June 27, 2021, at the DRG originally billed.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for inpatient hospital services provided to the enrollee on June 27, 2021, at the Diagnosis Related Group (DRG) originally billed.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for acupuncture services provided on August 9, 2022.
You asked the Plan to pay for these services. The Plan denied your request. The Plan says the benefit was exhausted prior to the date of service. Maximus overturned the Plans denial for insufficient information in the file regarding the previous visits. The Plan requested a reopen and provided additional information.
The Plan is correct in this case. The Plan must follow Medicare rules. The rules say for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments meeting certain requirements. The Plan covers 18 visits, and those visits are also combined with any chiropractic care reviewed. Based on the records provided by the Plan, 18 visits were exhausted prior to the date in question. Therefore, we decided that the Plan does not have to pay for acupuncture services provided on August 9, 2022.
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 this is the best option to provide a safe 
discharge for the enrollee. The Plan denied your request. The Plan says the enrollee's needs may be met in an 
alternate 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 the enrollee appears to be improving with treatment and should only require short-
term additional acute care services that can safely be provided at the current facility until more stable and 
appropriate for a lower level of care. The enrollee does not require services at the LTACH that are not already 
available at the current facility. Completion of treatment at the current facility is 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 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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee's 
condition has stabilized and does not require complex medical management, services needed may be provided 
safely in a lower 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 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. 
 
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 an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF services would be the most beneficial to the 
enrollee's recovery from hip and heart surgery. The Plan denied your request. The Plan says the enrollee does 
not meet Medicare guidelines for services in an IRF. 
 
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 that the complexity of the enrollee's nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may benefit from physical therapy 
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 an IRF admission and services.
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 this is medically necessary. The Plan denied your 
request. The Plan says this 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 
service is not medically necessary. Our physician reviewer found this enrollee has chronic obstructive 
pulmonary disease (COPD). There is no diagnosis of bronchiectasis, cystic fibrosis, or generalized 
neuromuscular disease. There is inadequate evidence that this device is safe and beneficial in the treatment of 
COPD. 
 
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 total electric hospital bed (E0265). 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that a total electric hospital bed is 
medically necessary for the enrollee. The Plan denied your request. The Plan says a total electric hospital bed is 
not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed (E0265).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the breast reduction and associated procedures (19318, 
14302, 64450 and 14302). 
 
You asked the Plan to pre-approve the surgical services. You say that the services are medically necessary. The 
Plan denied your request. The Plan says the services are not medically 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 surgical services. Our physician 
reviewer found the limited clinical documentation does not support that the coverage criteria established by 
LCD L35090 for the reduction mammaplasty have been met in this case. 
 
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 surgical services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the breast reduction and associated procedures (19318, 14302, 64450 and 14302).
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 services are medically necessary for 
you to get the care needed. The Plan denied your request. The Plan says that your medical needs are being met 
in the current setting. 
 
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 you were admitted with hepatic encephalopathy in the setting of sepsis. The 
record indicates that you have ongoing acute medical issues and still requires acute care services before 
transitioning to a lower level of care. You continue to receive acute care services, and these have not been 
denied. The medical record does not indicate that you require services that you 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve genicular RFA. You say that the services are necessary. The Plan denied 
your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not 
been met. 
 
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 RFA. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this is considered an experimental/investigational procedure. It is the subject of ongoing clinical 
trials in patients who have pain status post (s/p) total knee arthroplasty (TKA). Therefore, the request is deemed 
not medically reasonable and 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 genicular RFA have not been met. Therefore, we decided that the Plan does not 
have to pre-approve genicular radiofrequency ablation (RFA).