Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy visits. 
 
You asked the Plan to pre-approve additional physical therapy visits. You say that the enrollee presents with a 
decline in functional mobility. The Plan denied your request. The Plan says the enrollee has met the therapy 
cap. 
 
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 additional physical therapy visits. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found that the enrollee lives in a long-term care facility with 
staff assist and has had prior therapy for this condition. Our reviewer says that the unique skills of a 
professional therapist are not required to safely and effectively provide ongoing 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 additional physical therapy visits have not been met. Therefore, we decided that 
the Plan does not have to pre-approve additional physical therapy visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for an alcohol or other drug treatment program (H2036) 
provided on May 18, 2020. 
 
You asked the Plan to pay for an alcohol or other drug treatment program. You say that this service was 
provided in good faith. The Plan denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code H2036 is not supported in the medical record. Specifically, this code has a status 
indicator of "I." Medicare uses another code for reporting of, and payment for these services. Based on this 
information, we decided that Medicare rules for coverage of an alcohol or other drug treatment program have 
not been met. Therefore, we decided that the Plan does not have to pay for an alcohol or other drug treatment 
program (H2036) provided on May 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller (E2377), expandable controller 
harness (E2313), and electro connect (E2311). 
 
You asked the Plan to pre-approve an expandable controller (E2377), expandable controller harness (E2313), 
and electro connect (E2311). You say that the requested expandable controller (E2377), expandable controller 
harness (E2313), and electro connect (E2311) to control power tilt, recline and power elevating leg rests 
through the joystick are medically necessary. The Plan denied your request. The Plan says the requested 
expandable controller (E2377), expandable controller harness (E2313), and electro connect (E2311) to control 
power tilt, recline and power elevating leg rests through the joystick 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), 
expandable controller harness (E2313), and electro connect (E2311). Our reviewer says that the requested 
expandable controller (E2377), expandable controller harness (E2313), and electro connect (E2311) to control 
power tilt, recline and power elevating leg rests through the joystick are not medically necessary. Our physician 
reviewer found the health plan has approved a Group 3 power wheelchair with multiple power options without 
the Expandable Controlled, Expandable Controller Harness and Electro Connect. The power mobility device 
has its own control power options through three separate switches that can be used instead of the additional 
equipment that has been requested. 
 
According to the manufacturer the requested Expandable controller harness, controller and connect BTW 2 
system are needed when 3 or more actuators are being used.  Although there are three actuators being used the 
documentation supports that the member has the left upper extremity strength to adjust the wheelchair using the 
three switches that come with the wheelchair. The additional equipment is not medically 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 an expandable controller (E2377), expandable controller harness (E2313), and 
electro connect (E2311) have not been met. Therefore, we decided that the Plan does not have to pre-approve 
an expandable controller (E2377), expandable controller harness (E2313), and electro connect (E2311).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the $50 copayment charged for urgent care services provided 
on May 29, 2020. 
 
You asked the Plan to waive this copayment. You say that you and your wife went to get tested for Covid 
because you both had a cough and did not feel well. You do not feel this copayment should be charged. The 
Plan denied your request. The Plan says this copayment was charged based on the claim submitted by the 
provider, the treatment records and the Plan contract agreement. 
 
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 $50 
copayment for urgent care services. The medical records state you presented to urgent care for a cough and 
requested you be tested for Covid as you thought there was possible exposure as did your spouse. You had a 
mild cough however no other Covid symptoms. You were treated for a cough and told to call your primary care 
physician if symptoms worsened. You were told the test results for Covid would come back in a few days. You 
and your spouse self-referred to urgent care. You were not referred to urgent care by a physician thinking you 
had Covid or because you could not be seen at the office. The medical records do not show that you were 
treated for a positive diagnosis of Covid. Therefore, this copayment would not be waived as Covid treatment.  
 
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 $50 copayment charged for urgent care services provided on May 29, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency services provided on February 11, 2020. 
 
You asked the Plan to pay for the emergency services (99285). You say that the Plan should pay this claim. 
The Plan denied your request. The Plan says the documentation submitted supports CPT code 99284. 
 
The Plan follows Medicare billing and payment rules. The rules say that codes billed must accurately reflect 
the services provided.   
 
In this case, you billed CPT code 99285. The definition of CPT code 99285 is an emergency room visit for the 
evaluation and management of a patient which requires three components (taking into account the urgency of 
the clinical condition or the patient's mental status): 
 
1. a comprehensive history; 
2. a comprehensive examination; and 
3. medical decision making of high complexity. 
 
In addition, CPT code 99285 usually includes a presenting medical problem of high severity and immediate 
significant threat to life or physiologic function.  
 
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 emergency services (99285) Our 
reviewer says that the review indicates that the criteria for CPT 99285 was not met. Our reviewer found the 
review of the medical documentation indicates that medical decision making of high complexity was not 
documented. 
 
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 emergency services (99285) have not been met. Therefore, we decided that 
the Plan does not have to pay for the emergency services provided on February 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the wound debridement services (94597) and sterile 
medical/surgical supplies (0272)provided on October 29, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for the debridement. You say that the claim has not been paid in full or under the 
terms of the contract for the services provided. The Plan denied your request. The Plan says enrollee's must 
receive their medical services from an in-network provider with the exception being urgent or emergent 
services. Non-emergent services with non-contracted providers require prior authorization before services 
being rendered. 
 
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 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 the wound debridement services (94597) and 
sterile medical/surgical supplies (0272)provided on October 29, 2019 by an out of network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health skilled nursing services. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says you 
have no ongoing skilled needs. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
The file shows that 18 home health skilled nursing services were requested. The Plan has agreed to approve 2 
visits. 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 requested services. Our physician 
reviewer found that the most recent documentation indicates you have been medically stable. There is no 
indication that you have a feeding tube, parental medications or complex wound care issues. There is no 
indication that you have had any recent medication changes or hospitalizations. There has not been a recent 
decline in function. The documentation does not support that you require skilled nursing services beyond what 
has been approved by the Plan. You do not require skilled nursing services to improve your condition, or 
perform a maintenance program to maintain your condition or prevent deterioration. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve additional home health skilled nursing services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on June 23, 2020. 
 
You asked the Plan to pay for lab tests. You say that your lab performed all the tests that were ordered by the 
referring physician. The Plan denied your request. The Plan says the denial of payment for these services is 
correct, because the documentation does not show if a physician's order was given, how the enrollee came to 
this provider, the referring provider, or whether the services were medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific 
lab services is required for covered lab services.  
 
We looked at the file and Medicare rules. The documentation submitted does not include a valid physician 
order or clear intent to order the specific lab services billed on this claim. Based on this information, we 
decided that Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan 
does not have to pay for laboratory testing provided on June 23, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the $10 copayment charged for lab services provided on July 
29, 2020. 
 
You asked the Plan to waive this copayment. You say that this lab service was done during the annual physical 
which has no copayment. The Plan denied your request. The Plan says lab services are not included in the 
annual physical. 
 
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 $10 
copayment for lab services. The Plan is correct, lab services are not included in the payment to the provider for 
annual physical services. 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 $10 copayment charged for lab services provided on July 29, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an infusion pump and supplies (A4222 and E0781) provided 
on July 8, 2019, through April 28, 2019. 
 
You asked the Plan to pay for the supplies. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says payment for the administration of the drug or 
biological will also include payment for equipment used in furnishing the service. 
 
The Plan must follow Medicare rules. Medicare rules say that equipment, such as an external infusion pump 
used to begin administration of the drug or biological that the patient takes home to complete the infusion, is 
not separately billable. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the supplies have not been met. Specifically, payment for these supplies is bundled into the 
payment to the attending physician. Therefore, we decided that the Plan does not have to pay for an infusion 
pump and supplies (A4222 and E0781) provided on July 8, 2019, through April 28, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation system (E2300), harness 
(E2313), expandable controller (E2377) and electric connection (E2311). 
 
You asked the Plan to pre-approve the accessories. You say that you would like reconsideration because this 
equipment is medically necessary. The Plan denied your request. The Plan says this equipment is 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 the accessories. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation does not reveal that you require other types of proportional input devices or 
non-proportional input devices. You do not need to operate 3 or more powered seating actuators through the 
drive control, a separate display, other electronic devices, or an attendant control. Your upper extremity 
strength and function are sufficient for you to control any power options through their own individual switches. 

Additionally, per Medicare, the seat elevator is not primarily medical in nature. 
 
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 accessories have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power seat elevation system (E2300), harness (E2313), expandable controller (E2377) 
and electric connection (E2311).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee does not 
meet medical criteria for face-to-face supervision by a rehabilitation physician at least 3 times per week. The 
enrollee has medical needs that can be met in a lower level of care such as skilled nursing 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 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 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 spinal surgery. The medical problems are stable. There are no identified problems that 
need inpatient medical management. There are no complex nursing or rehabilitation needs. The enrollee does 
not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. The medical record supports a need for physical and occupational 
therapy, but it does not support a need for an intensive rehabilitation therapy program. There is not a reasonable 
expectation that the 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 IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the $100 copayment charged for computed tomography (CT) 
scan services provided on July 6, 2020. 
 
You asked the Plan to waive this copayment. You say that you pay insurance each month and feel this 
copayment is too high. The Plan denied your request. The Plan says this copayment was charged based on the 
services provided and the Plan contract agreement. 
 
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 $100 
copayment for outpatient diagnostic services such as a CT scan. 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 $100 copayment 
charged for computed tomography (CT) scan services provided on July 6, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network lab services provided on February 6, 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 and these lab 
services were ordered by a non-plan provider. 
 
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 lab services 
provided on February 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair (K0836) and accessories (E2311, 
E1002, E1028, E1012, E2601, E0955, E2361). 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that this is medically 
necessary. The Plan denied your request. The Plan says the medical necessity criteria are not met. 
 
The Plan follows Medicare rules. Medicare rules say that a power wheelchair is covered if it is medically 
necessary per the above guidance.  
 
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 power wheelchair and accessories. 
Our reviewer says that the requested items are not medically necessary. Our physician reviewer found the 
documentation indicates that the patient has a personal mobility deficit but the physician, home health and 
therapy documentation does not support that the deficit impairs participation in MRADLs in the home. The 
physician documentation reveals the patient uses a rollator and lacks strength to use a manual wheelchair. The 
documentation is not clear that the patient can safely  maneuver the power operated vehicle  in the home or that 
the requested power mobility device will significantly improve ADL performance in the home. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a power wheelchair (K0836) and accessories (E2311, E1002, E1028, 
E1012, E2601, E0955, E2361).