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

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee needs SNF care. The Plan denied your 
request. The Plan says based on Medicare guidelines, the requested SNF services do not meet the requirement 
for approval. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the wheelchair power seat elevation system (E2300). 
 
You asked the Plan to pre-approve the wheelchair power seat elevation system. You say that the item is 
medically necessary. The Plan denied your request. The Plan says this item is not primarily medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve the wheelchair power seat elevation system (E2300).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0120). 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you need transportation 
to your medical appointments. The Plan denied your request. The Plan says you have utilized the maximum 
number of transportation trips allowed per year. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 48 trips per year.  
 
   
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips (A0120).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for definitive urine drug testing (UDT) (G0483) provided on 
July 13, 2021. 
 
You asked the Plan to pay for drug testing. You say that this testing was medically necessary. The Plan denied 
your request. The Plan says the requested number of definitive urine drug classes were 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 drug testing. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the provided records do not document a need for definitive testing for any drug class other than 
barbiturates which was the only unexpected positive on the screening UDT. The number of classes tested in 
this case were 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 drug testing have not been met. Therefore, we decided that the Plan does not 
have to pay for definitive urine drug testing (UDT) (G0483) provided on July 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued use of a continuous positive airway pressure 
(CPAP) device. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says a compliance report to show adherence to therapy was not submitted. 
 
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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that compliance reports covering June to October 2022 show 0% of days with at least 4 hours per day. 
This does not meet minimum Medicare criteria and is not enough use to be effective. There is no evidence of a 
follow-up visit to address compliance issue. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve continued use of a continuous positive airway pressure (CPAP) device.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an occupational therapy visit. 
 
You asked the Plan to pre-approve an occupational therapy visit. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
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 an occupational therapy visit. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found your level of 
function has remained essentially the same and your improvement has plateaued. You continue to require 
assistance with showering and dressing, but this does not require the services of a skilled occupational 
therapist. Therefore, the 1 visit of additional occupational therapy cannot be considered 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 occupational therapy visit have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an occupational therapy visit.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency ambulance transportation (A0428) and 
ground mileage (A0425) provided on April 6, 2022. 
 
You asked the Plan to pay for the non-emergency ambulance transportation and ground mileage. The Plan 
denied your request. The Plan says ambulance transport to or from an outpatient office or facility for a 
scheduled appointment is not a Medicare covered benefit. 
 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. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the non-emergency ambulance 
transportation and ground mileage have been met. Medical records were not provided with this case. The Plan 
attempted to obtain this information, but it was not received. Without medical records, we are unable to 
determine if the non-emergency ambulance transportation and ground mileage were medically necessary for 
the enrollee. Therefore, we decided that the Plan does not have to pay for the non-emergency ambulance 
transportation (A0428) and ground mileage (A0425) provided on April 6, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is ready to be discharged to 
the next level of care. You say that the LTACH can render services that will improve the enrollee's condition 
and avoid unnecessary hospital readmissions. The Plan denied your request. The Plan says the LTACH services 
you are requesting do not meet the requirements for approval. 
 
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 does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. The Plan has approved ongoing care in the current acute 
care setting.  
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you are appealing the denied admission to the IRF with medical records. The Plan denied your request. The Plan says that the enrollee's medical needs can be met at a lower-level setting.
Our Medical director looked at the case file and the reopen request. At issue is coverage for IRF care. Our Medical Director states the available documentation in the case file does not support that there was a reasonable expectation that you would be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our Medical Director found that your condition did not meet Medicare criteria for SNF 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: 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. You say that you cannot go home, you are a fall risk, you need 
IRF services. The Plan denied your request. The Plan says the request 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 that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a (E2377) expandable controller, including all related electronics and mounting hardware, upgrade provided at initial issue, and (E2313) harness for upgrade to expandable controller.
You asked the Plan to provide coverage for the requested accessories. You say that at the time of the appeal, the requested accessories were medically necessary. The Plan denied your request. The Plan says the requested accessories exceeded the enrollees needs. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare will not pay for power wheelchair accessories that exceed the enrollees needs. The medical records were reviewed a second time. While the enrollee's right dominant side was affected due to a cerebrovascular accident, the enrollee retained full range of motion and strength on the left side. The approved power options (tilt-and-recline) and the power feature (power elevating leg rests) are operated by individual switches which can be fabricated at any desired size or shape and with any material, eliminating the need to control the approved power options and the power feature exclusively through the standard joystick that is part of the approved base. The Plan is correct that the condition on the right side would not have prevented the enrollee from using the left arm to operate the power wheelchair and the equipment could have been configured to accommodate this need. Therefore, we decided that the Plan does not have to provide coverage for a (E2377) expandable controller, including all related electronics and mounting hardware, upgrade provided at initial issue, and (E2313) harness for upgrade to expandable controller.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 billed for date of service July 9, 2022. 
 
You asked the Plan to pay for the billed services. You say that the providers were of different specialties. The 
Plan denied your request. The Plan says a follow up visit was performed. 
 
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, the CPT Code Manual definition of code 99223 is initial hospital care, per day, for the evaluation 
and management of a patient. The file shows that an inpatient hospital care code was billed previously during 
the same inpatient admission. The claim information shows that the rendering provider was the same for both 
claims. Follow-up visits in the facility setting shall be billed as subsequent hospital care visits. Based on this 
information, we decided that Medicare rules for coverage of the billed services have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure code 99223 billed for date of service July 9, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you don't feel well, and you need more time in the 
SNF. The Plan denied your request. The Plan says your request for approval of continued admission in a SNF 
does not meet the requirements for approval. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the medical records do not document the need for daily inpatient skilled nursing 
services. Provided records do not document a significant decline in your functional status to necessitate further 
daily inpatient skilled therapy services. Your care needs can be provided at a lower level. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee is not stable enough to be discharged 
home. The Plan denied your request. The Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that daily skilled services are not required to establish a maintenance program or to 
prevent deterioration of the enrollees condition. There is no documentation that the enrollee requires services 
on an inpatient basis, only in a skilled nursing facility setting. The enrollees care needs can, as a practical 
matter, be provided at a lower level of 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on June 13, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. The Plan denied your request. The Plan 
says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on June 13, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for power seat elevation system (E2300), backup Quantum camera (K0108), attendant control (E2331), JS mount track hardware (K0108), a footplate (K0108), and footplate width extension bracket (K0108).
You asked the Plan to provide coverage for any of these accessories. You say that at the time of the appeal, this equipment was medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria for the requested accessories were not met. Maximus overturned the Plans denial. The Plan requested a reopen and state that Maximus did not apply the correct criteria.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare does not cover equipment that does not serve a direct medical purpose or exceeds the enrollees needs. The rules specifically state the E2300 power seat elevation system is not covered under any circumstance. A back up camera, attendant control, JS mount track hardware, and additional footplates also do not serve a medical purpose for equipment used in the home and are not covered by Medicare. Therefore, we decided that the Plan does not have to provide coverage for power seat elevation system (E2300), backup Quantum camera (K0108), attendant control (E2331), JS mount track hardware (K0108), a footplate (K0108), and footplate width extension bracket (K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mastectomy bras and associated sales tax you purchased 
from June 9, 2022, to June 29, 2022. 
 
You asked the Plan to pay for the mastectomy bras and sales tax. You say that this provider is the only one in 
your area and that these items are covered by Medicare. The Plan denied your request. The Plan says you did 
not use a Medicare-enrolled provider for these items, so they are not covered. The Plan must follow Medicare 
rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare 
program. Review of the file and Medicare records indicates that the provider at issue is not enrolled in the 
Medicare program. Therefore, we decided that the Plan does not have to pay for mastectomy bras and 
associated sales tax you purchased from June 9, 2022, to June 29, 2022.