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

 
We decided that the Plan does not have to waive the copayments for physical therapy (PT) services provided 
from August 9, 2021, to September 2, 2021. 
 
You asked the Plan to waive the copayments for the PT services. You say that you were an inpatient resident 
and should not have copayments. The Plan denied your request. The Plan says you have been charged the 
correct cost sharing 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 $20 
copayment for each outpatient rehabilitation service visit.  
 
The file shows you had a total of 18 PT visits from August 9, 2021, to September 2, 2021. Therefore, you have 
been asked to pay a $20 copayment for each visit for the PT services. The total for all visits is $360 ($20 
copayment x 18 visits = $360). Please note that the file does not indicate that you were under inpatient status at 
the time the services were received. The PT services fall within the Outpatient Rehabilitation 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 for physical therapy (PT) services provided from 
August 9, 2021, to September 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for COVID-19 tests purchased on December 22, 2021. 
 
You asked the Plan to pay for these test kits. You say that the wait for free testing was too long. The Plan 
denied your request. The Plan says these test kits are not a covered benefit. 
 
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 states what is covered in the 
pick your perks benefit. COVID-19 over the counter self-test kits are not covered under this benefit. You had 
the option to take advantage of the free testing offered by your local agencies. Therefore, we decided that the 
Plan does not have to pay for COVID-19 tests purchased on December 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection represented by code E2310 for 
a power wheelchair. 
 
You asked the Plan to pre-approve an electronic connection represented by code E2310. You say that this 
accessory is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are 
not 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 an electronic 
connection represented by code E2310. Our physician reviewer found an electronic connection allows the 
person in the power wheelchair to control the power options by the use of a joystick. The documentation does 
not support that the enrollee is unable to use the control switches that come with the power features on the 
power wheelchair. Medicare coverage criteria are not 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 this accessory have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an electronic connection represented by code E2310 for a power wheelchair.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services provided to the enrollee on September 
1, 2021. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says ordering a multi-drug panel of definitive (confirmation) urine drug tests that are not used 
in management of the member 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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the provider reported a definitive drug test for 22 or more drug classes with diagnosis of Long term drug 
therapy with pain unspecified. The documentation does not support the level of service  billed, as it is not 
medically necessary to test for drug classes that are not used to treat the enrollee. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for drug testing services provided to the enrollee on September 1, 2021.
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 requested admission to an IRF is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found there are no acute rehabilitation or nursing needs identified or noted in the record. The enrollee is medically stable and does not need physician supervision 3 times per week (at a minimum) for 
the ongoing management of any active or acute exacerbations of chronic medical conditions. At the current 
functional level, the enrollee does not need or will tolerate intensive therapies, consisting of at least 3 hours of 
therapy per day at least 5 days per week with multidisciplinary approach to daily therapy in an IRF. The 
enrollee's rehab needs can be met safely at a lower intensity and alternate setting such as in a skilled nursing 
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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to reimburse you for travel and lodging costs from August 12, 2021 to August 31, 
2021. 
 
You asked the Plan to reimburse you for the costs. You say that there was only partial reimbursement. The Plan 
denied your request. The Plan says that they cannot pay for this. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The plan has not substantiated their denial. The plan has not given any specific 
reason as to why the claim was only partially reimbursed. The plan has not provided enough information to 
verify their denial. Therefore, we decided that the Plan has to reimburse you for travel and lodging costs from 
August 12, 2021 to August 31, 2021.  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on November 9, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the provider did not bill as required by Medicare coding regulations. 
 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 76705 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for imaging services provided to the enrollee on November 9, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ultrasound services provided to the enrollee on November 5, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this service should not be unbundled. 
 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 76705 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for ultrasound services provided to the enrollee on November 5, 
2021.
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 need a higher level of treatment to help you 
regain your maximum functionality. The Plan denied your request. The Plan says IRF care is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. 
 Our physician reviewer found you are medically stable and do not need physician supervision 3 times per week 
(at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical 
conditions. You do not need intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days 
per week with multidisciplinary approach to daily therapy in an IRF. Skilled nursing facility admission can 
accomplish the same functional gains. IRF admission is not medically necessary based on lack of medical 
complexity and lack of acute rehab nursing needs. 
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ultrasound services provided to the enrollee on November 
17, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the provider did not bill as required by Medicare coding regulations. 
 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 76705 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for ultrasound services provided to the enrollee on November 17, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on September 2, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the provider did not bill as required by Medicare coding regulations. 
 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 93042 
is a column II code to column I code 99291. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for imaging services provided to the enrollee on September 2, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 6 additional physical therapy home health visits 
 
You asked the Plan to pre-approve additional home health visits. You say that you feel more physical therapy is 
needed for this enrollee. The Plan denied your request. The Plan says a home exercise program should be 
sufficient for the patient at this point and no further skilled services are needed. 
 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. 
 
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 home health visits. Our 
reviewer says that additional home health services are not medically necessary. Our physician reviewer found 
based on the medical records provided there is no documentation that additional skilled therapy services are 
required to effectively provide treatment, care and/or services in order to improve the enrollee's level of 
function or to establish/perform a maintenance program to maintain the enrollee's level of function and/or 
prevent deterioration. No medical notes from the enrollee's treating physician are provided documenting a need 
for additional skilled therapy services beyond what have already been provided. The enrollee has been 
receiving physical therapy services since December 29, 2021. and is improving with her ambulatory distance 
with a rolling walker and is stand-by assist for transfers and has been taught a home exercise program and is 
compliant with it. Further utilization of the home exercise program appears appropriate at this point to improve 
the enrollee's ambulation and endurance. 
 
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 home health visits have not been met. Therefore, we decided that the 
Plan does not have to pre-approve 6 additional physical therapy home health visits
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a raised toilet seat. 
 
You asked the Plan to pre-approve a raised toilet seat. The Plan denied your request. The Plan says this item is 
not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered 
because they are not primarily medical in nature.  
 
While a raised toilet seat may be appropriate for H. De Long, neither the Plan nor Medicare offers coverage of 
this item. Therefore, we decided that the Plan does not have to pre-approve a raised toilet seat.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy services provided from 
September 30, 2020, to July 14, 2021. 
 
You asked the Plan to waive the copayment for physical therapy. You say that you do not feel you should have 
to pay the copays. The Plan denied your request. The Plan says the copays applied are correct. 
 
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 $40 
copayment per day for Medicare-covered physical therapy services. There were nine visits, resulting in a total 
copayment amount of $360. 
 
 You have been asked to pay a $40 copayment for each physical therapy visit. Physical therapy falls within the 
Outpatient rehabilitation 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 copayment for 
physical therapy services provided from September 30, 2020, to July 14, 2021.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a telehealth office visit provided to the enrollee on February 
28, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says a research of claims history reveals that the enrollee has never been seen by this group. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
The file does not contain documentation of an established relationship between the enrollee and the provider. 
Without a record showing that this provider is actually treating the enrollee, the criteria for coverage of this 
testing have not been met. Based on this information, we decided that Medicare rules for coverage of the services have not been met. 
Therefore, we decided that the Plan does not have to pay for a telehealth office visit provided to the enrollee on 
February 28, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 5 home health aide visits. 
 
You asked the Plan to pre-approve the home health aide visits. You say that 5 home health aide visits are 
medically necessary. The Plan denied your request. The Plan says the medical records do not support the need 
of the home health aid services. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or 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 the home health aide visits. Our 
reviewer says that the requested home health aid services are not medically necessary. Our physician reviewer 
found the female enrollee has a history of paraplegia secondary to multiple sclerosis. The enrollee began 
receiving home health care services on March 14, 2013. Our doctor found that the requested services such as 
personal care, bathing, hair care, and dressing do not require skilled medical or nursing care and would be considered custodial. The requested home health aide services are not reasonable and necessary to the 
treatment of the patients illness or injury by skilled professional staff. 
 
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 home health aide visits have not been met. Therefore, we decided that the 
Plan does not have to pre-approve 5 home health aide visits.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide services. 
 
You asked the Plan to pre-approve home health aide services. You say that these services are medically 
necessary. The Plan denied your request. The Plan says you have caregivers who help with your activities of 
daily living and you do not require home health aide services. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or 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 home health aide services. Our 
reviewer says that home health aid services are not medically necessary. Our physician reviewer found you 
have diagnoses of sacral pressure ulcer, Alzheimer's disease, breast cancer, chronic inflammatory 
demyelinating polyneuropathy, and dementia. Home health services including home health aide began on 
January 35, 2022. You are requesting a home health aide to assist with personal care needs. The requested services such as shower, shampoo, and light housekeeping do not require skilled medical or 
nursing care and would be considered custodial. Medicare does not pay for custodial services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health aide services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve home health aide services.