Persius/hicric huggingface dataset:
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 the enrollee has a hip infection and has been 
prescribed medication that can only be administered while the enrollee is getting therapy. The Plan denied your 
request. The Plan says the inpatient rehabilitation facility (IRF) services you are requesting do not meet the 
requirements for approval.  
 
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. The enrollee 
was admitted for lumbar spine surgery. Medical problems are stable. The enrollee does not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While the medical record supports a need for physical and/or occupational therapy, there is 
no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires IRF level of care as their 
current needs cannot be safely met at a lower level of care. The Plan denied your request. The Plan says an IRF 
admission is not medically necessary.  
 
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 enrollee's condition is complex and fragile. Also, it is expected that the 
enrollee will participate in and benefit from services to include at minimum PT, OT, physician oversight of 
polypharmacy, and case manager coordination of any additional services that might be needed to ensure they 
can make a sustainable return to their current living environment.  
 
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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee from February
25, 2022, through February 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 required billing criteria were not met.

Maximus overturned the Plans denial. The Plan requested a reopen and noted that the Plan received and
accepted NOA claim, with Admission date and from date listed, which was past the 30-day allowable submission period. Plan received a final claim, on November 09, 2022, with an admission date listed. As the NOA claim was received past
the 30-day allowable submission period, payment for the final claim was denied. Per Medicare Claims
Processing Manual, Chapter 10, Section 10.1.10.3, Submission of the Notice of Admission (NOA):
home health agencies (HHAs) shall no longer submit Requests for Anticipated Payment (RAPS -TOB 0322)
for any home health period of care with a from date on or after January 1, 2022. Instead, for each admission to
home health, the HHA notifies Medicare systems via submission of an NOA. NOAs must be submitted timely.
A timely-filed NOA is submitted to and accepted by the A/B MAC (HHH) within five calendar days after
admission date. In instances where an NOA is not timely-filed, Medicare shall reduce the payment for a period
of care, including outlier payment, by the number of days from the home health admission date to the date the
NOA is submitted to, and accepted by, the A/B MAC (HHH), divided by 30. No per-visit payments shall be
made for visits that occurred on days that fall within the period of care prior to the submission of the NOA.
This reduction shall be a provider liability, and the provider shall not bill the enrollee for it. Per the above
Medicare guidelines, the Plan has correctly denied the final claim for payment as the NOA was not received
within the 30-day allowable submission period that would have allowed for even a partial payment.

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, could not be paid as billed due to the omission of an appropriate NOA.
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 February 25, 2022, through February 25,
2022.
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 you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says the LTACH services requested do not meet 
the requirements for approval.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee is receiving acute hospital care, and acute care services have not 
been denied. There are no required medical services identified that are available at the LTACH, that are not 
available at the current health care setting being offered by the Plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 
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: 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 still need around the clock care after your major 
surgery because you are too weak to care for yourself. The Plan denied your request. The Plan says an IRF 
admission is not reasonable and necessary.  
 
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 nursing, medical, and rehabilitation needs do not require an 
acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, at an 
intensive rehabilitation therapy program. You continue to have a need for skilled therapy with ongoing safety 
concerns and a potential for functional improvement however, the documentation does not support that you 
would meet criteria for admission to an acute inpatient rehabilitation facility. You can receive further services 
at a lower level of 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block (64454). 
 
You asked the Plan to pre-approve a genicular nerve block. 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 a genicular nerve block. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found genicular nerve blocks and genicular nerve radiofrequency ablation are considered 
investigational and not medically necessary for the treatment of chronic knee pain, including, but not limited to 
any of the following:  degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee replacement; as a treatment following knee replacement; or as a treatment for individuals who are not 
candidates for knee replacement surgery. The review has determined that the requested right knee genicular 
nerve block is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a genicular nerve block (64454).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for OralCDx Brush Test services provided to the enrollee on September 26, 2022.

You asked the Plan to pay for this testing. The Plan denied your request. The Plan says there were no medical records submitted to support the claim billed. Maximus overturned the Plans denial for no medical records. The Plan requested a reopen and stated that they agree that it cannot be determined if the criteria were met for this testing based only on the lab results.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.

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 this testing were met. Therefore, we decided that the Plan does not have to pay for OralCDx Brush Test services provided to the enrollee on September 26, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the excess skin removal surgery for the arm.  
 
You asked the Plan to pre-approve the skin removal surgery. You say that you feel that this surgery is 
medically necessary for you. The Plan denied your request. The Plan says this is considered cosmetic in nature 
and is not a covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
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 skin removal surgery. Our reviewer 
says that the requested procedure is not shown to be reasonable and necessary at this time.  Our reviewer found 
based on the medical records provided, there is no documentation that the excision of excessive skin and 
subcutaneous tissue (includes lipectomy) of the arm (15836) at issue in this case meets all Medicare criteria for medically reasonable and necessary for the patient. Provided records in this case do not document any 
pathology affecting the arms (rash, ulcerations or infections) related to the excess skin. Records do not 
document failure of any conservative, non-surgical treatments for the patient's reported "significant sweating, 
skin rubbing and issues with odor." Records do not clarify that the requested procedure is required for the 
"treatment of illness or injury or to improve the functioning of a malformed body member" as required by the 
Medicare rules.  
 
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 skin removal surgery have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the excess skin removal surgery for the arm.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for acupuncture provided from December 7, 2022, to December
28, 2022.

You asked the Plan to pay for these services. The Plan denied your request. The Plan says the acupuncture
benefit was exhausted prior to these dates of service. Maximus overturned the Plans denial for a lack of claim
information in the case file to show these benefits were exhausted. The Plan requested a reopen and provided
the required claim information.

The Plan is correct in this case. The rules say that acupuncture services are not covered by Medicare. However,
the Plan offers an acupuncture benefit that exceeds Medicare coverage. For that reason, the Plan's coverage
rules apply in this case. The Plan covers 6 visits in or out of network. The records show you exhausted 6 visits
prior to the dates in question. Therefore, we decided that the Plan does not have to pay for acupuncture
provided from December 7, 2022, to December 28, 2022.
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 requires hourly nursing care, 
daily physician management and continuous pulse oximetry monitoring. The Plan denied your request. The 
Plan says the LTACH services are not medically necessary. 
 
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 does not require services at the LTACH that are not available at the 
current facility being provided by the Plan. Transfer to an LTACH is not medically necessary as it would not 
be clinically advantageous.  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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service April 11, 
2023. 
 You asked the Plan to pay for procedure code 70450. You say that the claim should be paid. The Plan denied 
your request. The Plan says payment for code 70450 is bundled into payment for code 70496. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service April 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the routine eye examination rendered on August 8, 2022.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services are not covered out-of-network.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan covers one routine eye examination and up to two refractions annually; these services are
not covered from an out-of-network provider.

We looked at the file and the Plan's rules. The file shows that you received a routine eye examination from an
out-of-network provider on August 8, 2022. Based on this information, we decided that the Plan's rules for
coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the
routine eye examination rendered on August 8, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for inpatient hospital services provided on April 22, 2021 to 
April 26, 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 this 
service was medically necessary. The Plan denied your request. The Plan says DRG 371 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.   
 
In this case, you billed the inpatient services provided with DRG 371. 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 hospital services at the DRG originally billed. Our reviewer says 
that the billed DRG is not supported. Our physician reviewer found there is no evidence that the enrollee ever 
had altered mental status or metabolic encephalopathy. There is no evidence that the enrollee had overt kidney 
failure. As such, the billing of G93.41 and N17.9 is not supported.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on April 22, 2021 to April 26, 2021, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Guardant Reveal Post-Surgery Minimal Residual Disease Bundle (81479) provided on October 7, 2022.

You asked the Plan to pay for this testing. 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 per the DEX Diagnostic Exchange Registry, DEX Z-Code Z00D5 has a coverage status of "Not Covered" for Medicare claims. Per this guideline, the Plan has correctly denied the claim for payment as Z-Code Z00D5 is not covered for the MoIDX program.

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 could not be paid as billed due to an error with the Z-Code reported. Medicare rules for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for Guardant Reveal Post-Surgery Minimal Residual Disease Bundle (81479) provided on October 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided the Plan does not have to pay for oxygen equipment purchased out of network on October 18,
2022.

You asked the Plan to pay for this oxygen equipment. The Plan denied your request. The Plan says the
purchased oxygen equipment is not a covered benefit. Maximus overturned the Plans denial. The Plan
requested a reopen and stated that Maximus did not apply the correct coverage language.

The Plan is correct in this case. The Plan follows Medicare rules. Medicare rules state that purchased oxygen
equipment is statutorily non-covered. You purchased oxygen equipment without prior authorization out of
network. You did not follow your Plan contract rules when you purchased this equipment. Therefore, we
decided that the Plan does not have to pay for oxygen equipment purchased out of network on October 18,
2022.