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

We decided that the Plan does not have to pay for the testing provided to the enrollee on October 11, 2022.

You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the claim for this
molecular pathology testing did not include the required unique identifier. Maximus overturned the Plan's
denial. The Plan requested a reopening and stated that Maximus did not apply the correct criteria.

The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue,
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the
coverage status is listed in the DEXTM Diagnostics Exchange.

We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier
was reported. The Z-code on the claim is not listed as valid for the CPT code billed. 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 the testing provided to the enrollee on October 11, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for presumptive drug testing (80307) provided on March 30, 2021.

You asked the Plan to pay for this testing. The Plan denied your request. The Plan says the service was already
paid on a previous claim. Maximus overturned the Plans denial for insufficient claim information in the case
file. The Plan requested a reopen and provided the required claim information.

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 records show this service was previously paid by the Plan making the
claim in question invalid. Medicare rules for coverage of this testing have not been met. Therefore, we decided
that the Plan does not have to pay for presumptive drug testing (80307) provided on March 30, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee from October
27, 2022, to November 25, 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 noted that the provider submitted the Notice of Admission (NOA) on December
6, 2022 for a date of service beginning October 27, 2022. According to Medicare guidelines, the deadline for
submission of the Home Health claims Notice of Admission (NOA) has to be within 5 days of the start of care.
The Plan submitted documentation that confirms proof that the NOA was not received within five days of the
start of service.

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, we show the NOA was not submitted within five days of the first date of
service. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan
does not have to pay for home health services provided to the enrollee from October 27, 2022, to November 25,
2022.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health care provided to the enrollee from January
5, 2022, to January 28, 2022.

You asked the Plan to pay for the home health care. The Plan denied your request. The Plan says the NOA was
not received timely. As such, this final claim was correctly denied. Maximus overturned the Plan's denial. The
Plan requested a reopening and stated that the did not receive the NOA timely. The Plan is correct in this case.
The rules say that an NOA must be submitted within 5 days of the start of care date for home health services.
NOAs which are received more than 30 days from the timely filing date result in no payment being made for
the episode of care. In this case, the start of care date was January 5, 2022. The case file does not include a
valid NOA as being received. As more than 30 days passed between the timely filing date and the NOA receipt,
no payment can be made on this claim. Therefore, we decided that the Plan does not have to pay for the home
health care provided to the enrollee from January 5, 2022, to January 28, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for long term acute care hospital (LTACH)
services for the enrollee.

You asked the Plan to provide coverage for LTACH services. You say that at the time of the appeal, this
transfer was medically necessary. The Plan denied your request. The Plan says there were not services offered
by the LTACH that were not being provided in the inpatient setting being covered by the Plan. Maximus
overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct
criteria.

The Plan is correct in this case. 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. Long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general,
LTACHs do not provide clinical services that are materially different than those of short-term acute care
hospitals. The enrollee was receiving acute hospital care covered by the Plan.

The documentation does not support that the enrollee in this case required services at the LTACH that were not
available at the acute care hospital where she was receiving care. There were no required medical services
identified that were available at the LTACH, that were not available at the health care setting offered by the
health plan. The documentation does not support that the requested LTACH services were medically necessary
and reasonable for the diagnosis and condition of the enrollee at the time. Medicare rules for coverage of the
LTACH services have not been met. Therefore, we decided that the Plan does not have to provide coverage for
long term acute care hospital (LTACH) services for the enrollee.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 99285 provided to the enrollee on April 12,
2022.

You asked the Plan to pay for procedure code 99285. You say that you would like the Plan to reconsider their
denial of payment. The Plan denied your request. The Plan says that they are not the enrollee's primary insurer.
The Plan is correct in this case. The Plan has provided documentation indicating they were the secondary
insurer at the time these services were received by the enrollee and that the enrollee had insurance through a
different entity. The rules state that Medicare plans are considered secondary insurers when an enrollee has
another type of insurance. This means that the Plan is not responsible for paying for services until the claim for
those services has gone to the primary insurer. However, plans are still required to coordinate their benefits
with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the
Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to
send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement
to the primary insurer.


The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed you
to send the bill the primary insurer and provide the Explanation of Benefits. As the secondary insurer, the Plan
cannot be held responsible for procedure code 99285 until the primary insurer has denied the claim for these
services. Therefore, we decided that the Plan does not have to pay for procedure code 99285 provided to the
enrollee on April 12, 2022.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a Sacroiliac (SI) joint injection for the enrollee.

You asked the Plan to provide coverage for an SI joint injection. You say that at the time of the appeal, this
injection 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 must follow Medicare rules. Medicare requires all stated criteria be met before coverage is approved.
In particular, the clinical findings and/or imaging studies do not suggest any other diagnosed or obvious cause
of the lumbosacral pain. Our physician reviewer noted the enrollee has a normal neurological exam and
symptoms which may be related to right SI joint. The enrollee previously had a Medrol dose pack with
temporary relief of symptoms. As this suggests a specific diagnosis or obvious cause of the pain, the Medicare
coverage criteria were not met. Therefore, we decided that the Plan does not have to provide coverage for a
Sacroiliac (SI) joint injection for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for continued skilled nursing facility (SNF) care
beyond July 5, 2023.

You asked the Plan to provide coverage for continued SNF care. You say that at the time of the appeal,
continued care was medically necessary. The Plan denied your request. The Plan says continued care was not
medically necessary. Maximus overturned the Plans denial because the records lacked a signed Notice of Noncoverage.
The Plan requested a reopen and provided the signed 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 the medical records provided, continued care beyond July 5, 2023, was not medically necessary. The
enrollee's care no longer required daily skilled nursing or daily skilled therapy services on an inpatient basis.
Therefore, we decided that the Plan does not have to provide coverage for continued skilled nursing facility
(SNF) care beyond July 5, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the upper 
spinal canal. 
 
You asked the Plan to pre-approve the MRI. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the enrollee's records do not show documentation of physical exam results 
that included a detailed nervous system was performed since the symptoms started that support imaging. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 MRI. Our reviewer says that the 
MRI is not medically necessary. Our physician reviewer found there was no provided x-ray report of the 
cervical spine, no reported trial of conservative treatment, or evidence of a red flag diagnosis of the upper spine 
or plans for surgery to justify advanced imaging of the neck. Therefore, the MRI of the cervical spine will be 
considered not medically necessary based on the provided documentation.  
 
 
 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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a magnetic resonance imaging (MRI) of the upper spinal canal.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve vagal nerve neurostimulator implantation (64568). 
 
You asked the Plan to pre-approve vagal nerve neurostimulator implantation. 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 vagal nerve neurostimulator 
implantation. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found because a vagal nerve stimulator is not yet part of routine 
practice, it is not believed that this is medically reasonable or necessary and remains experimental. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of vagal nerve neurostimulator implantation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve vagal nerve neurostimulator implantation (64568).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospitalization provided from January 7, 2023, 
to January 10, 2023. 
 You asked the Plan to pay for the inpatient hospitalization. You say that the inpatient stay was medically 
necessary at the acute level of care, and you would like the denial to be overturned. The Plan denied your 
request. The Plan says the information received does not support that criterion were met for inpatient 
hospitalization and the original denial is upheld. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 inpatient hospitalization. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the patient presented to the emergency department with persistent moderate to severe 
headache and neck discomfort with light sensitivity for 2 weeks and complaints of right-hand numbness. The 
patient was examined which was unremarkable besides light sensitivity. Imaging showed no acute findings. 
Electrocardiogram was normal sinus rhythm without acute abnormality. Our reviewer found that the labs 
showed blood urea nitrogen (BUN) 32 and Creatinine 1.4. The patient was treated with intravenous fluids and 
eye drops. Vitals remained stable. Workup was continued following admission. Our physician reviewer also 
found that at the time of admission, it was not expected that the patient would have required hospital care that 
would have crossed 2 midnights as acute stroke was ruled out and it was not expected that the patient would 
have an adverse event if not admitted to the hospital during the remaining workup and consultations which 
would have only taken one more 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 inpatient hospitalization have not been met. Therefore, we decided that the 
Plan does not have to pay for the inpatient hospitalization provided from January 7, 2023, to January 10, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 standard power wheelchair (K0848) and 
additional items and accessories (codes E2361 x2, E1028, E2377, and E2313). 
 
You asked the Plan to pre-approve a group 3 standard power wheelchair and additional items and accessories. 
The Plan denied your request. The Plan says based on the composite of information, the enrollee does not meet 
the medical necessity for a powered wheelchair. 
 
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 3 standard power wheelchair 
and additional items and accessories. Our reviewer says that the criteria for coverage have not been met. Our 
physician reviewer found the enrollee has residual from a stroke and walks in the home with an assistive 
device. Our reviewer also found that the enrollee does not require a power wheelchair to manage activities of 
daily living in the 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 a group 3 standard power wheelchair and additional items and accessories have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 standard power 
wheelchair (K0848) and additional items and accessories (codes E2361 x2, E1028, E2377, and E2313).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF)
admission and services.

You asked the Plan to provide coverage for IRF care. You say that at the time of the appeal, IRF admission was
medically necessary. The Plan denied your request. The Plan says the Medicare coverage criteria were not met
Maximus overturned the Plans denial. The Plan requested a reopen and stated Maximus did not apply the
correct criteria.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for IRF services.
The medical records show you were admitted to the hospital on July 6, 2023, with a urinary tract infection with
severe sepsis, acute-on-chronic kidney disease, and acute metabolic encephalopathy. On July 13, 2023, your
mental status had returned to baseline, vital signs were normal, and your leukocytosis had resolved. You were
walking 15 feet or more in the hallway. The Plan is correct in this case. The clinical documentation does not
support that the complexity of your nursing, medical and rehabilitation needs required 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 provide coverage for acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 standard power wheelchair (K0823). 
 
You asked the Plan to pre-approve a group 2 standard power wheelchair. The Plan denied your request. The 
Plan says this request 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 2 standard power wheelchair. 
Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found you have 
Parkinson's disease, and the plan denied the wheelchair stating the provider indicated you could not manage a 
wheelchair. Our reviewer found that the provider indicated you could not manage a scooter, and you live alone. 
No functional data is provided. Our physician reviewer also found that the Plan's rationale for denial is not 
consistent with the record, but the record provides no evidence you require a power wheelchair to manage your 
activities of daily living in the 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 a group 2 standard power wheelchair have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a group 2 standard power wheelchair (K0823).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care for the
enrollee beyond July 21, 2023.

You asked the Plan to pre-approve continued SNF care. You say that at the time of the appeal, continued SNF
admission was medically necessary. The Plan denied your request. The Plan says the Medicare coverage
criteria for continued care were not met. Maximus overturned the Plans denial for a lack of notice of noncoverage
in the case file. The Plan requested a reopen and provided the required documentation.

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, an inpatient level of SNF care was no longer necessary as of July 21, 2023. The enrollee no longer
required daily skilled therapy or daily skilled nursing services at an inpatient level of care. Therefore, we
decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care for the enrollee
beyond July 21, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 23, 2023, billed with 
codes 87500, 87641, 87798, 87653, 87640, 87491, and 87481. 
 
You asked the Plan to pay for the genetic testing billed. You say that the coding is approved by Medicare. 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. The file shows that a urinary tract infection panel was provided. We looked at the file and Medicare rules. This 
NGS panel was not billed with a single 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 May 23, 2023, billed with codes 87500, 87641, 87798, 87653, 
87640, 87491, and 87481.