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

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377) and reinforced tilt 
(K0108). 
 
You asked the Plan to pre-approve an expandable controller (E2377) and reinforced tilt (K0108). You say that 
the requested expandable controller (E2377) and reinforced tilt are medically necessary. The Plan denied your 
 
 
request. The Plan says the requested expandable controller (E2377) and reinforced tilt are not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an expandable controller (E2377). Our 
reviewer says that the requested expandable controller (E2377) is not medically necessary. Our physician 
reviewer found the documentation does not reveal that the enrollee requires other types of proportional input 
devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) or non-
proportional input devices (e.g., sip and puff, head array, etc.) The enrollee does not need to operate 3 or more 
powered seating actuators through the drive control, a separate display (i.e., for alternate control devices), other 
electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive 
control), or an attendant control. The enrollee's left upper extremity strength is sufficient for the enrollee to 
control any power options through their own individual switches. 
 
Furthermore, you requested K0108 reinforced tilt along with E1002 power tilt. The Plan approved E1002 
power tilt. K0108 reinforced tilt is unbundled from E1002 power tilt and cannot be requested separately. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an expandable controller (E2377) and reinforced tilt (K0108) have not been 
met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377) and 
reinforced tilt (K0108).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prefabricated post and core in addition to a crown for 
tooth #5 (D2954). 
 
You asked the Plan to pre-approve prefabricated post and core in addition to a crown for tooth #5. You say that 
the service is necessary. The Plan denied your request. The Plan says the requested service is not a covered 
benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
prefabricated post and core in addition to a crown for tooth #5 (D2954).
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 stay is medically necessary. The Plan 
denied your request. The Plan says the stay is 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 you appear to be improving; however, additional short-term acute care services is 
required for additional ventilation weaning attempts and monitoring which can safely be performed at the 
current facility. You do not require services at the LTACH that are not already available at the current facility. 
There are no services at the LTACH that are not already available and covered at the current facility. Therefore, 
this request for LTACH services will be considered not medically necessary at this time. Transfer may be 
considered when treatment has completed and additional ventilation weaning attempts confirm long-term 
status. 
 
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 2 power wheelchair with accessories (high 
back, adjustable armrests, batteries). 
 
You asked the Plan to pre-approve Group 2 power wheelchair. You say that you are requesting approval. The 
Plan denied your request. The Plan says the denial of authorization for this device is correct, because the 
enrollee was able to ambulate 91 feet without an assistive device and therefore a heavy-duty four-wheeled 
walker appears to be more appropriate for him. 
 
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 patient's 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 Group 2 power wheelchair. Our 
reviewer says that the enrollee does not meet the Medicare criteria for the requested wheelchair. Our physician 
reviewer found the documentation reveals that the enrollee has a personal mobility deficit. The documentation 
is conflicting on the enrollee's need for this wheelchair for mobility-related activities of daily living (MRADLs) 
in the home. The physician note states that he needs it to obtain goods and services. The documentation does 
not reveal supporting evidence of an inability to use a manual wheelchair or walker given the enrollee's upper 
body strength and his ambulatory ability of 91 feet. The physical therapy document states that the enrollee is 
unable to propel distances for activities of daily living in a manual wheelchair, but there is no evidence of trial 
of a manual wheelchair or walker and no physician objective detailed neuromuscular examination. The 
documentation is not clear that the enrollee's home provides adequate space for safe maneuvering of this power 
mobility device.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Group 2 power wheelchair have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Group 2 power wheelchair with accessories (high back, adjustable 
armrests, batteries).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forlaboratory services provided from June 15, 2020, to July 15, 2020.You asked the Plan to waive the copayments forlaboratory services. You say that you disagree with the charges because you were never charged in the past and did not know they would bill it as outpatient.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 copayment for lab services. You received laboratory services on June 15, 2020, at an outpatient hospital facility. Therefore, you are responsible to pay the $50 copayment. You received laboratory services on July 15, 2020, at an outpatient hospital facility. Therefore, you are responsible to pay the allowed amount of $11.57, which is less than the $50 copayment.The total amount you owe is: $61.57. You have been asked to pay the total copayment amount of $61.57 for laboratory services. Laboratory services fallwithin the outpatient hospital services benefit category. This means that you have been asked to pay 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 forlaboratory services provided from June 15, 2020, to July 15, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on 
January 2, 2020. 
 
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 enrollee did not have prior authorization for out of network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. 
The Plan has network providers available who can provide 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 out of network physician 
services provided to the enrollee on January 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a gym membership.You asked the Plan to pre-approve the gym membership. You say that going to the gym will improve your physical ailments, overall health, help reduce pain medications you take and keep you from developing additional health issues. The Plan denied your request. The Plan says your Plan does not offera supplemental benefit which covers a fitness program or health club membership.The Plan must follow Medicare rules. The rules say that Medicare does not cover gym benefits. The services at issue in this appeal are gym benefits. Therefore, we decided that the Plan does not have to pre-approve a gym membership.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided from March 21, 2020, through May 18, 
2020. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the home health dates of service are invalid and a corrected claim is required. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Based on this information, we decided that Medicare rules for coverage of the services have not been met. The 
provider did not submit the required information to verify the dates of service. Therefore, this is being upheld 
for insufficient records. Therefore, we decided that the Plan does not have to pay for the services provided from 
March 21, 2020, through May 18, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diagnostic radiology services (CPT code 70145) provided 
on June 10, 2020. 
 
You asked the Plan to pay for CPT code 71045. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
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 71045 
has a bundled relationship with code 36573 and cannot be paid as billed. This code cannot be paid as a separate 
line item unless an appropriate modifier is billed to represent the service as being separate and distinct. Based 
on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does 
not have to pay for the diagnostic radiology services (CPT code 70145) provided on June 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ankle foot orthosis (L1971) provided on June 12, 2020. 
 
You asked the Plan to pay for the ankle foot orthosis. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says there is no evidence of an established 
relationship between the member and ordering physician. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the ankle foot orthosis. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found provided records do not document any evidence of an established relationship (with a 
face-to-face or telehealth visit or physical examination) between the enrollee and the ordering physician. 
 
 
 
 
 
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 ankle foot orthosis have not been met. Therefore, we decided that the Plan 
does not have to pay for the ankle foot orthosis (L1971) provided on June 12, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for proton beam therapy provided to the enrollee from April 30, 
2020, to May 15, 2020. 
 
You asked the Plan to pay for these services. You say that this claim should be paid because the enrollee is 
registered in a retrospective registry study. The Plan denied your request. The Plan says proton beam therapy is 
only covered for enrollees registered in certified clinical trial. A retrospective registry study is not the same as a 
clinical trial. In addition, the Plan states the claim submitted for payment has discrepancies between what was 
approved, and the number of treatments provided. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Medicare does not cover investigational services. The records provided show 
participation in a retrospective study only. There are discrepancies as well with the claim submitted.  
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 pay for proton beam therapy provided to the enrollee from 
April 30, 2020, to May 15, 2020.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pre-approve 24 speech therapy visits. 
 
You asked the Plan to pre-approve 24 speech therapy visits. You say that the services are necessary. The Plan 
denied your request. The Plan says that based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 24 speech therapy visits. Our reviewer 
says that the services are medically necessary. Our physician reviewer found based on the enrollee's medical 
condition and diagnoses and medical records indicating substantial improvement on current cognitive and 
speech therapy sessions, it is medically appropriate to continue these sessions at this time. They are acceptable 
and effectively proven modalities in post-cerebral infarction and hemorrhage medical treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 24 speech therapy visits have been met. Therefore, we decided that the Plan has 
to pre-approve 24 speech therapy visits.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the diagnostic radiology services provided 
on January 22, 2020. 
 
You asked the Plan to waive the deductible for the diagnostic radiology services. You say that you feel you 
should not be responsible for this cost share amount and you would like the Plan to reconsider your request. 
The Plan denied your request. The Plan says you received outpatient diagnostic radiology services on the date 
of service at issue in this appeal. The Plan says that the correct amount has applied towards the deductible per 
your contract with the Plan. 
 
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 $100 deductible that must be paid before the Plan will pay their share 
for Outpatient diagnostic tests.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category Outpatient 
diagnostic tests. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $100 
deductible that must be paid before the Plan will pay their share for Outpatient diagnostic tests. This cost 
sharing is a contractual obligation that had not been met at the time the diagnostic radiology services was 
received on January 22, 2020. Therefore, we decided that the Plan does not have to waive the deductible for the 
diagnostic radiology services provided on January 22, 2020.  
 
Maximus Federal Services read your letter and knows that you may have a question regarding your enrollment 
in the Plan. Maximus Federal Services cannot answer enrollment questions. Maximus Federal Services is 
sending a copy of your case file and your letter to the Kansas City CMS Regional Office so that it can look into 
your enrollment question.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF services. 
 
You asked the Plan to pre-approve the SNF services. You say that you would like reconsideration because the 
member requires more care until their condition clears up. 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 above 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 the SNF services. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the member does not require the 
necessary services 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 the SNF services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve SNF 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 is too sick to be moved and needs to 
remain under physician management with aggressive therapy. The Plan denied your request. The Plan says the 
denial of authorization for IRF service is correct. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 enrollee does not require the intensity of services provided in an IRF. 
Specifically, the enrollee is not shown to require 15 hours per week of rehabilitative services and regular 
physician evaluation. The enrollee's care needs can be met at a lower level of care such as skilled nursing 
facility (SNF) or sub-acute rehabilitation (SAR). 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device. 
 
You asked the Plan to pay for a pneumatic compression device. You say that the device is necessary to prevent 
deep vein thrombosis. The Plan denied your request. The Plan says the pneumatic compression device is not 
covered by Medicare to prevent deep vein thrombosis during and/or following surgery and PCDs billed by 
E0675 are not covered. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism is a preventive service. PCDs billed by E0675 are not 
covered. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided 
that the Plan does not have to pay for a pneumatic compression device.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Stioloto Respimat inhale spray (J3535). 
 
You asked the Plan to pre-approve Stioloto Respimat. You say that this medication would help to keep the 
enrollee out of the hospital with frequent COPD exasperation. The Plan denied your request. The Plan says the 
requested drug is considered self-administered. The Plan says self-administered drugs are covered under a 
Medicare Part D prescription drug plan. The Plan also says the requested drug is not covered under Medicare 
Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Stioloto Respimat inhale 
spray (J3535).