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

 
We decided that the Plan does not have to pay for the medical services provided on April 8, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the retroperitoneal ultrasound (76770). You say that you would like 
reconsideration because these services were rendered in good faith. The Plan denied your request. The Plan 
says the services provided require prior authorization and non was obtained. 
 
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 requested provider in this case is not a network provider with the Plan. 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 medical services provided on April 8, 2020 by 
an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro myoelectric orthosis (L8702). 
 
You asked the Plan to pre-approve the MyoPro myoelectric orthosis. You say that you would like 
reconsideration because this equipment is medically necessary. The Plan denied your request. The Plan says 
this equipment is investigational. 
 
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 the MyoPro myoelectric orthosis. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the requested robotic orthosis is not proven to be more beneficial for 
treatment of the member's medical condition/function than any available standard therapy. 
 
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 MyoPro myoelectric orthosis have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the MyoPro myoelectric orthosis (L8702).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Neuromuscular stimulator, electronic shock unit (E0745) 
provided June 1, 2020. 
 
You asked the Plan to pay for the electronic shock unit. You say that please see the attached documentation to 
prove medical necessity. The Plan denied your request. The Plan says there is no actual physical exam. All 
information was provided over the phone. There are no clinical notes from the enrollee's primary health 
provider and no documented attempts to contact the enrollee's local physician. The enrollee is not in an eligible 
geographical area that qualifies for telehealth services. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for Neuromuscular stimulator, 
electronic shock unit (E0745) provided June 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the visit you had with an emergency 
medicine specialist on February 11, 2020. 
 
You asked the Plan to reduce the copayment for the visit with an emergency medicine specialist. You say that 
you called the plan and were told that this visit would be covered. You said that you have a $10 copayment if 
you don't see a specialist and that you did not see a specialist. The Plan denied your request. The Plan says you 
were charged the $45 copayment correctly because the doctor you saw is a specialist in emergency medicine.  
This doctor is not a primary care doctor. 
 
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 $45 
copayment for visits with a specialist.  
 
You have been asked to pay a $45 copayment for the visit with an emergency medicine specialist. The visit 
with an emergency medicine specialist falls within the visits with a specialist 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 reduce the copayment for the visit you had with an emergency medicine specialist on February 
11, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bone density study provided on May 29, 2020. 
 
You asked the Plan to pay for the bone density study. The Plan denied your request. The Plan says this is not 
covered for screening purposes. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The test at issue in this appeal, the bone density study, was requested solely for screening purposes. Medicare 
does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay 
for bone density study provided on May 29, 2020.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found the enrollee is with a past 
medical history of chronic inflammatory demyelinating polyneuropathy, Guillian Barre syndrome and 
fibromyalgia who is in his private residence with weakness, numbness and pain in all extremities. There is no 
recent reported hospitalization. He is weak and unsteady and has been evaluated by physical therapy. He is 
walking 22 feet with a rolling walker with contact guard assistance and is minimum to moderate assist for 
transfers and stand-by assist for activities of daily living. No other unstable medical conditions are reported. 
 
Based on the medical records provided the complexity of the enrollee's nursing, medical and rehabilitation 
needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
The enrollee does require physical therapy and occupational therapy services but based on the medical records 
provided the enrollee does not require an intensive inpatient rehabilitation therapy program. 
 
 
 
There is no documentation that the enrollee requires the intensive rehabilitation therapy program provided in an 
inpatient rehabilitation facility. 
 
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 LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says you are 
receiving appropriate inpatient acute care, and you do not require transfer to a LTACH. 
 
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 do not require services at the LTACH that are not already available at the current 
facility. Our reviewer found that there are no services at the LTACH that you require that are not already 
available and covered at the current facility. Our physician reviewer also found that continued care at the 
current facility appears appropriate for now, and transfer to a lower level of care may be considered soon. 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF 
admission. 
 
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 admission to a SNF. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled 
nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse required to 
safely and effectively provide medically necessary and reasonable treatment in a SNF.  The enrollee does not 
have complex wound care or other ongoing SNF level SN need. The enrollee's functional level does not require 
skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely 
 
 
and effectively provide medically necessary and reasonable treatment only in a SNF. The enrollee does not 
require skilled nursing or skilled therapy services (or a combination of these services) on a daily basis in a 
SNF. As a practical matter, this enrollee does not require the necessary services on an inpatient basis, only in a 
skilled nursing facility 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 admission to a SNF have not been met. Therefore, we decided that the Plan 
does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a knee orthosis (L1830) provided to the enrollee on January 
7, 2020. 
 
You asked the Plan to pay for the orthosis. You say that the orthosis is necessary for the enrollee. The Plan 
denied your request. The Plan says there is no evidence of recent injury or surgery to the knee. 
 
The Plan must follow Medicare rules. Medicare rules say a knee immobilizer without joints (L1830), or a knee 
orthosis with adjustable knee joints (L1832, L1833), or a knee orthosis, with an adjustable flexion and 
extension joint that provides both medial-lateral and rotation control (K0901, K0902, L1843, L1845), are 
covered if the beneficiary has had recent injury to or a surgical procedure on the knee(s). The record does not 
show evidence of recent injury or surgery to the knee. Therefore, we decided that the Plan does not have to pay 
for a knee orthosis (L1830) provided to the enrollee on January 7, 2020.
Appeal type: Inpatient Hospital
Decision: Partially Favorable

 
We decided that the Plan has to adjust the copayment for the inpatient mental health care provided from 
February 22, 2020 to March 9, 2020. We also decided that the Plan does not have to waive the copayment for 
the inpatient mental health care provided.  
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan says that the copayment has been applied correctly to the services provided.  
 
We decided that the Plan has to adjust the copayment for the inpatient mental health care. The Plan 
applied a copayment of $1,965 ($393 copayment x 6 days) for inpatient hospital care. However, the services 
provided to you were inpatient mental health care. Your liability in this case is $1,758 ($293 copay x 6 days). 
Therefore, we decided that the Plan has to adjust the copayment for the inpatient mental health care provided 
from $1,965 to $1,758. 
 
 
We also decided that the Plan does not have to waive the copayment for the inpatient mental health care. 
The Plan contract states that enrollees must pay a $293 copayment each day, for days 1 to 6 and a $0 
copayment each day, for days 7 and beyond, for inpatient mental health care. 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 copayment for the inpatient mental health care provided from February 22, 2020 to March 9, 2020.  
 
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. 
 
Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus 
Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the 
appropriate Quality Improvement Organization for further review.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found the enrollee is with a past 
medical history of diabetes, neuropathy, osteogenesis imperfecta, hypertension and prior stroke who presented 
to the acute hospital on 10/12/2020 with a non-healing wound of the right foot with osteomyelitis. She was 
treated in the hospital with a right below the knee amputation. She will need a PICC line for antibiotics through 
11/11/2020. She is weak and deconditioned and is working with physical and occupational therapy. She is 
hopping with a front-wheeled walker a few steps with minimal assistance and is minimum to moderate assist 
for transfers and activities of daily living. She is reported to be medically stable for discharge. 
 
Based on the medical records provided the complexity of the enrollee's nursing, medical and rehabilitation 
needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
The enrollee does require physical therapy and occupational therapy services but based on the medical records 
provided the enrollee does not require an intensive inpatient rehabilitation therapy program. There is concern 
 
 
that the enrollee will not be able to fully participate in and benefit from the intensive rehabilitation therapy 
program provided in an inpatient rehabilitation facility. 
 
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 lumbar-sacral orthosis (L0650) and a shoulder orthosis 
(L3970) provided to the enrollee on May 15, 2020. 
 
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation does not indicate services are necessary for treatment of the 
enrollee's condition. 
 
The rules say for Medicare to consider coverage and payment for any item or service, the information 
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical 
documentation and confirm that Medicare coverage criteria have been met. When conducting a review of a 
covered DME item, ordered by a physician, the contractor shall ensure that the physician saw the beneficiary 
and conducted a face-to-face assessment.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the durable medical equipment have not been met. Specifically, medical records do not support a 
prior face-to-face examination with the ordering physician within 6 months of ordering the DME or an 
appropriate use of telehealth. The submitted consultation notes do not support that a physical examination was 
performed. The information submitted does not confirm that Medicare coverage criteria have been met. 
Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) and a shoulder 
orthosis (L3970) provided to the enrollee on May 15, 2020.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found the enrollee is with a past 
medical history of spina bifida and a right lower extremity amputation who presented to the acute hospital on 
10/14/2020 with injuries related to a motor vehicle crash. He is wheelchair bound at baseline; he was hit by an 
SUV while crossing the street in his wheelchair. He was treated in the hospital for left rib fractures and 
multiple abrasions and lacerations. He is weak and deconditioned and is working with physical and 
occupational therapy. He is in a wheelchair which is his baseline and is maximum assist for transfers and 
activities of daily living. He is reported to be medically stable for discharge. 
 
Based on the medical records provided the complexity of the enrollee's nursing, medical and rehabilitation 
needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
The enrollee does require physical therapy and occupational therapy services but based on the medical records 
provided the enrollee does not require an intensive inpatient rehabilitation therapy program. There is no 
 
 
documentation that the enrollee requires the intensive rehabilitation therapy program provided in an inpatient 
rehabilitation facility. 
 
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 pre-approve a Myoelectric upper extremity orthotic device(L8702). 
 
You asked the Plan to pre-approve the Myoelectric upper extremity orthotic device. You say that the device is 
medically necessary. The Plan denied your request. The Plan says coverage criteria has 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 the Myoelectric upper extremity 
orthotic device. Our reviewer says that the requested items are not considered medically reasonable and 
necessary in this case. Our physician reviewer found under Medicare guidelines, the request is not medically 
necessary because this device has deluxe features that exceed the enrollee's need and replaces, rather than 
improves the function of the arm. 
 
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 Myoelectric upper extremity orthotic device have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a Myoelectric upper extremity orthotic device(L8702).