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

 
We decided that the Plan does not have to waive the copayment for physical therapy services provided on 
December 29, 2021. 
 
You asked the Plan to waive the copayment for physical therapy services. You say that you have not had to pay 
for these services in the past. The Plan denied your request. The Plan says the copayment amount charged is 
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 for each Medicare-covered physical therapy visit.  
 
 
 
 
 
 
 You have been asked to pay a $40 copayment for physical therapy services. Physical therapy 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 copayment 
for physical therapy services provided on December 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the porcelain/ceramic crown provided on November 17, 2021. 
 
You asked the Plan to pay for the crown. You say that you would like reconsideration because this crown is 
medically necessary due to the medication you are taking for your condition. The Plan denied your request. The 
Plan says you have exceeded the frequency limitation for this 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 
among those covered under this benefit, but frequency limitations apply. The record indicates that you received 
a crown on January 20, 2021. The crown at issue has exceeded the contracted frequency limitation. Therefore, 
we decided that the Plan does not have to pay for the porcelain/ceramic crown provided on November 17, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 sessions of therapeutic procedure, one or more areas, 
each 15 minutes; massage (97124), to be provided by a licensed massage therapist. 
 
You asked the Plan to pre-approve massage therapy. You say that the requested services are medically 
necessary. The Plan denied your request. The Plan says the claim denied correctly. 
 
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, 
we decided that the Plan does not have to pre-approve 8 sessions of therapeutic procedure, one or more areas, 
each 15 minutes; massage (97124), to be provided by a licensed massage therapist.
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 these services are medically necessary. The Plan 
denied your request. The Plan says that you do not need an intensive program with a team of health care 
professionals and doctors that specialize in complex medical needs as well as rehab. 
 
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.  
 The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You were admitted for head trauma and scalp 
laceration after being struck by a scooter while walking. Your medical problems are stable. There are no 
complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While you have a 
need for physical and/or occupational therapy, there is no documentation of a need for an intensive 
rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found 
that your condition does not meet Medicare criteria for IRF care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive or reduce this copayment.
You asked the Plan to waive this copayment. You say that you do not believe this copayment is correct. The
Plan denied your request. The Plan says this copayment was charged based on the claim submitted by your
provider. Maximus partially overturned the Plans denial stating it was not clear the provider was in an
ambulatory surgical center. The Plan requested a reopen and provided additional information to show this
service was provided in an ambulatory center and the staff who treated you are ambulatory center licensed
staff.
The Plan is correct in this case. 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 $200 copayment for outpatient ambulatory center services. The documentation
provided shows you were treatment by a facility licensed as an ambulatory center. 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 he
copayment for the venous catheter removal provided on August 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung 
cancer screening provided to the enrollee on October 29, 2021. 
 
You asked the Plan to pre-approve the requested LDCT scan. You say that this should be paid for. The Plan 
denied your request. The Plan says the enrollee was 80 years old at the time of service, which is inappropriate 
for this service. 
 The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung 
cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.  
 
We reviewed the file and the Medicare rules. We find that the enrollee was 80 years old at the time of service. 
Therefore, we decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) 
scan for lung cancer screening provided to the enrollee on October 29, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically reasonable 
and necessary. The Plan denied your request. The Plan says rules for LTACH care have not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was admitted with sacral decubitus ulcer and osteomyelitis in the setting 
of quadriplegia. The record indicates that the enrollee requires ongoing acute care services before discharge to 
a lower level of care. The enrollee continues to receive acute care services, and these have not been denied. The 
medical record does not indicate that the enrollee requires services that he is not currently receiving but that 
would be available at the LTACH facility. The elements of the coverage rules are not satisfied. The requested 
service cannot be recommended 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture services (97810, 97811) provided from 
December 22, 2021, to December 29, 2021. 
 
You asked the Plan to pay for acupuncture. You say that these services were medically necessary. The Plan 
denied your request. The Plan says the provider in this case is not a legally qualified physician. 
 The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plans rules apply in this case.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the services at issue were not provided by a physician 
in accordance with state requirements, or by a physician assistant, nurse practitioner/clinical nurse specialist, or 
auxiliary personnel meeting certain licensure requirements, nor were these services performed under the 
supervision of a physician. Therefore, we decided that the Plan does not have to pay for the acupuncture 
services (97810, 97811) provided from December 22, 2021, to December 29, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injections provided on December 2, 2021. 
 
You asked the Plan to pay for the injections. You say that the records support medical necessity and $1,126.65 
is owed. The Plan denied your request. The Plan says CPT code J0894 remains denied as a non-pass-through 
drug identified and was billed without any associated outpatient procedures.  The Plan must follow Medicare rules. The rules say that claims containing drugs and biological HCPCS codes 
with non-pass-through status (SI = K) that are reported without an OPPS payable procedure (SI = J1, J2, P, Q1, 
Q2, Q3, R, S, T, U, V) are returned to the provider (edit 99). 
 
We find that the injections are not supported in the medical record. Specifically, CPT code J0894 has a status 
indicator of K and was billed without a payable procedure. Based on this information, we decided that 
Medicare rules for coverage of the injections have not been met. Therefore, we decided that the Plan does not 
have to pay for the injections provided on December 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the FreeStyle Libre Continuous Glucose Monitor (CGM) supplied on December 9, 2021.
You asked the Plan to pay for the FreeStyle Libre CGM. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says neither the packing/shipping information, nor proof of delivery document matches the date of service (DOS) on the claim.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid proof of delivery for the supplies provided in this case. Specifically, the date of service on the claim does not match the shipping or delivery date. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the FreeStyle Libre Continuous Glucose Monitor (CGM) supplied on December 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CxBladder Detect (0012M) provided February 1, 2021. 
 
You asked the Plan to pay for the genetic testing. You say that the medical records provided support the 
necessity of the services in dispute. The Plan denied your request. The Plan says the request does not meet 
Medicare rules because review of medical literature and clinical practice guidelines do not support that clinical 
utility of CxBladder Detect. 
 
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 genetic testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee is a 71-year-old female with microscopic hematuria, benign neoplasm of the right 
kidney, and urinary frequency. Urinalysis was positive for small blood. The review has determined that the 
medical records provided do not meet the requirements listed in the LCD for Medicare coverage. 
 
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 genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pay for CxBladder Detect (0012M) provided February 1, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that an LTACH is the most appropriate level 
of care for the enrollee as she has had several denials form skilled nursing facilities for being too medically 
complex but is stable for transfer to an LTACH for medical care and rehabilitation. The Plan denied your 
request. The Plan says the guidelines for coverage have not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was admitted to acute care with failure to thrive in the setting of 
advanced endometrial cancer complicated by kidney injury and asthma. She is requiring total parenteral 
nutrition (TPN.) Palliative care was consulted. Recent notes describe the enrollee has having a poor prognosis 
overall and as being more appropriate for palliative treatment only. The enrollee appears to be somewhat 
unstable without a permanent feeding source and has a poor prognosis. They should only require short-term additional acute care services that can safely be completed at the current facility until more appropriate for a 
lower level of care. The enrollee does not require services at the LTACH that are not already available at the 
current facility. There are no services at the LTACH that the enrollee requires that are not already available and 
covered at the current facility. Transfer to an LTACH is not medically necessary at this time. Transfer to a 
lower level of care may be considered soon when treatment is completed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous positive airway pressure (CPAP) device 
provided on August 12, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the CPAP device. You say that you would like reconsideration because you were 
told that you could file purchase a device on your own and submit a claim. The Plan denied your request. The 
Plan says out-of-network services were not authorized. 
 
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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the continuous positive airway pressure (CPAP) 
device provided on August 12, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an emergency room visit (99284-25) and related services (96374, J2405, 96376, 96375, J3010, J1885. 36000, 99070, A4216, A4209, A4649, A4616, 81000, 80053, 80076, 85025, 74176) provided on September 16, 2020.
You asked the Plan to pay for an emergency room visit and related services. You say that this provider is eligible to bill Medicare. The Plan denied your request. The Plan says these services cannot be paid as billed.
The Plan must follow Medicare rules. Medicare rules say that modifier 25 is used to report significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service. We looked at the file and Medicare rules. The emergency room visit was billed with modifier 25, but the record does not show that there was a separately identifiable service provided by the same physician on this date of service to necessitate this modifier. Based on this information, we decided that Medicare rules for coverage of an emergency room visit and related services have not been met. Therefore, we decided that the Plan does not have to pay for an emergency room visit (99284-25) and related services (96374, J2405, 96376, 96375, J3010, J1885. 36000, 99070, A4216, A4209, A4649, A4616, 81000, 80053, 80076, 85025, 74176) provided on September 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Subsequent Nursing Facility Care provided on October 5, 
2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Subsequent Nursing Facility Care. You say that you would like to appeal the 
denial of the claim. The Plan denied your request. The Plan says the provider is out-of-network and there was 
an Invalid authorization. 
 
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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for Subsequent Nursing Facility Care provided on 
October 5, 2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on November 29, 
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 an appropriate modifier was not 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 70450 
is a column II code to column I code 70496. 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 29, 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 enrollee is at risk for hospital acquired infections. 
You say that the enrollee is not able to safely care for herself at home. The Plan denied your request. The Plan 
says the guidelines for coverage have not been met. The Plan says that the enrollee can safely receive the 
services needed in other settings. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the 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 chest pressure, hypotension, and a urinary tract infection. The enrollee's medical problems are 
stable. 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. While the enrollee has a need for physical and/or occupational therapy, there is no 
documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that this 
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 acute inpatient rehabilitation facility (IRF) admission and services.