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

We decided that the Plan does not have to pre-approve a Dexcom G7 continuous glucose monitor (CGM) and
supply allowance.

You asked the Plan to pre-approve these services. You say that you have a fear of needles and the CGM is
more convenient. The Plan denied your request. The Plan says you do not meet the criteria for coverage.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage
have been met.

We looked at the file and Medicare rules. The documentation indicates that you do not treat with insulin or
have a documented history of low blood pressure (hypoglycemia). Based on this information, we decided that
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a Dexcom G7 continuous glucose monitor (CGM) and supply allowance.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee would benefit from SNF services and 
never received the full 21 days of therapy. The Plan denied your request. The Plan says the SNF services are 
not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in an SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent, genicular nerve 
branches including imaging guidance, when performed (64624). 
 
You asked the Plan to pre-approve nerve ablation. You say that you are requesting reconsideration for left knee 
genicular nerve ablation. The Plan denied your request. The Plan says the request is not medically necessary 
because the current medical literature does not support this service to be reasonable and 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 nerve ablation. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the record indicates that the enrollee has left knee pain following knee arthroplasty for 
osteoarthritis. There is insufficient literature to support the safety and efficacy, as defined by Medicare rules, of 
the requested service. The record provided does not establish the medical necessity and reasonableness, as 
defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. The 
requested service is not 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 nerve ablation have not been met. Therefore, we decided that the Plan does not 
have to pre-approve destruction by neurolytic agent, genicular nerve branches including imaging guidance, 
when performed (64624).
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 received some physical therapy and are getting 
some strength back, but you believe you need more intense therapy. You say you need more therapy than what 
would be provided at a skilled nursing facility. The Plan denied your request. The Plan says you do not meet 
Medicare guidelines for services in an inpatient rehabilitation facility.  
 
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 hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require 
treatment by multiple therapies, including either physical or occupational therapy, at an intensive rehabilitation 
therapy program. You continue to have a need for skilled therapy however, the documentation doesnt support 
that you meet criteria for admission to an acute inpatient rehabilitation facility. There is no indication that you 
would require skilled rehabilitation in an IRF, participating in rehabilitation services 15 hours a week, under 
the supervision of a physician with at least three visits weekly to regain or maintain your functional status. 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: 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 say that you disagree with the denial for the 
admission to an IRF. The Plan denied your request. The Plan says the required services can be provided in an 
alternate setting.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollees medical, rehabilitation, and nursing needs does not 
require acute hospital inpatient rehabilitation stay with an interdisciplinary approach to rehabilitative care. The 
enrollees rehabilitation needs can be safely provided in an alternate and low intensity 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 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: Lab
Decision: Favorable

 
We decided that the Plan has to pre-approve Tempus xF liquid biopsy testing. 
 
You asked the Plan to pre-approve Tempus xF testing. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says that the enrollee does not meet criteria for this testing. 
 
The Plan follows Medicare rules. Medicare rules state that next generation sequencing tests may be covered if 
certain criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Tempus xF testing. Our reviewer says 
that the enrollee meets criteria for this testing. Our physician reviewer found the enrollee meets all the criteria 
above having a recurrent metastatic cancer. Previously NGS Omniseq was performed and the new lesion in 
pancreas is different and Tempus NGS has been ordered. The patient and providers are seeking further 
treatment with targeted therapy. Tempus has FDA approval for diagnostic purposes and is indicated for solid 
tumors. There is a report template to specify treatment options with summary of targetable mutations.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Tempus xF testing have been met. Therefore, we decided that the Plan has to 
pre-approve Tempus xF liquid biopsy testing.  
 
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 pre-approve proton beam therapy. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that proton beam therapy is covered when specific 
criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found there is no documentation showing that 
accepted constraints would not be met with intensity modulated radiation therapy (IMRT)/volumetric 
modulated arc therapy (VMAT), or that the proton plan would reduce exposures in a clinically meaningful way 
for this enrollee. There is no plausible reason why IMRT would be unacceptable or that proton beam therapy 
would offer a clinically meaningful benefit over the standard of care. The proton beam therapy is not 
reasonable or medically necessary 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve proton beam therapy.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services provided to the enrollee on
November 18, 2022, by an out-of-network (OON) provider.

You asked the Plan to pay for the psychotherapy services. You say that you disagree with the Plan's denial. The
Plan denied your request. The Plan says that the services are not payable. Maximus overturned the Plan's
denial because of a lack of information. The Plan requested a reopening and stated that out-of-network services
are not covered. The Plan has also provided the 2022 EOC for review. The Plan is correct in this case. 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 requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the items/services at issue in this appeal. 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 psychotherapy services provided to the
enrollee on November 18, 2022, by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the cardiac rehabilitation services
provided from July 1, 2022, through September 22, 2022.

You asked the Plan to waive the copayments for the cardiac rehabilitation services. You say that the coding
was incorrect and would like someone to look into it. The Plan denied your request. The Plan says this cost
sharing was charged correctly. Maximus partially overturned the Plan's denial. The Plan requested a reopening
and stated that we did not process the appeal correctly. The Plan is correct in this case. The appeal request from
you was requesting a waiver of the copayment for cardiac rehabilitation services and did not request a costsharing
waiver for a CT (computed tomography) scan. You have been asked to pay a $30 copayment for each
of the cardiac rehabilitation services. This item/service falls within the Cardiac rehabilitation services benefit
category. This means that you have been asked to pay less than the correct amount based on your contract with
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.
Therefore, we decided that the Plan does not have to waive the copayments for the cardiac rehabilitation
services provided from July 1, 2022, through September 22, 2022
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee has been in hospital for over 30 days and 
is needing to be transferred to regain maximum function and more therapy to build his strength back up. The 
Plan denied your request. The Plan says the records do not show that the enrollee's rehabilitation complexity 
requiring frequent visits and monitoring by an rehabilitation doctor at least three times a week. The Plan says 
services may be provided at 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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the enrollee's medical record overall significantly complies with the various documentation requirements 
for IRF admission.  The enrollees condition is in fact complex and fragile, and there is every reason to expect 
that he will participate in and benefit from IRF-level services to include at minimum physical and occupational 
therapy, nutritionist, physician oversight of polypharmacy, and case manager coordination of any additional 
services that might be needed to make a sustainable return home, as well as avoid preventable re-admissions to 
the acute hospital. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: 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 enrollee needs this level of care. The 
Plan denied your request. The Plan says the enrollee's needs can be safely managed at the current facility until 
they are more stable for transfer to another 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 does not require services at the LTACH that are not already available at 
the acute care hospital. 
 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle, group 1 heavy duty, patient 
weight capacity 301 to 450 pounds (K0801) and a cylinder tank carrier (E2208). 
 
You asked the Plan to pre-approve a wheelchair and accessory. You say that you currently have a pride scooter 
and cannot use the smaller option because it is not safe. You would like to be approved for a replacement 
scooter or repair of the battery on the scooter. The Plan denied your request. The Plan says your current scooter 
is damaged due to hit and runs. You do not meet criteria for a heavy-duty scooter which is indicated for 
enrollees weighing 301-450 pounds. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a wheelchair and accessory have not been met. Specifically, Medicare rules show that a heavy-duty 
wheelchair is indicated for enrollees weighing 301-450 pounds. The records show that your weight is below 
301 pounds. Therefore, we decided that the Plan does not have to pre-approve a power operated vehicle, group 
1 heavy duty, patient weight capacity 301 to 450 pounds (K0801) and a cylinder tank carrier (E2208).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services billed for dates of 
service September 21, 2022, to September 30, 2022. 
 
You asked the Plan to pay for the SNF services. You say that you billed this claim correctly. The Plan denied 
your request. The Plan says you billed an invalid HIPPS code. 
 
The Plan must follow Medicare rules. Medicare rules say that HIPPS codes are five-digit codes used for SNF 
billing. In this case, the HIPPS code you submitted on the claim only has 4 digits.  As noted in the above rule, 
HIPPS codes require five digits. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the SNF services have not been met. Therefore, we decided that the Plan does not have to pay for 
skilled nursing facility (SNF) services billed for dates of service September 21, 2022, to September 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit received on June 7, 2023. 
 
You asked the Plan to pay for the office visit. You say that you disagree with the Plans decision. The Plan 
denied your request. The Plan says this claim was processed correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $0 copayment when combined with your Medicaid benefit.  
The item or service you asked the Plan to pay for falls within the physician benefit category. The Plan has 
followed Medicare rules by clearly disclosing in the contract that there is $0 copayment when processed with 
your Medicaid benefits, which applies to the office visit. Therefore, we decided that the Plan does not have to 
pay for the office visit received on June 7, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the medical records provided support the 
need for the requested LTACH admission. The Plan denied your request. The Plan says that based on Medicare 
guidelines and the information we have about the enrollee's condition, they do not meet all of 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 considered medically reasonable and necessary in this case. Our physician 
reviewer found the clinical documentation shows the enrollee requires ongoing ventilatory support and 
telemetry for monitoring of medical comorbidities that would only be available in an acute care setting (would 
not be available in a skilled nursing facility or inpatient rehabilitation facility). The enrollee also requires 
interdisciplinary neurorehabilitation related to primary diagnosis of intraparenchymal hemorrhage and would 
be expected to require specified inpatient services for longer than 24 days thus LTACH criteria have been met. 
 
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 been met. Therefore, we decided that the Plan has to 
pre-approve long term acute care hospital (LTACH) services.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.