Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seating system (E1007), an addition to power 
seating system, power leg elevation system (E1010), a power seat elevation system (E2300), an electronic 
connection between wheelchair controller and 2 or more power seating system motors (E2311), an attendant 
control (K2331) and a wheelchair component or accessory, not otherwise specified (K0108). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that the enrollee's power wheelchair needs 
extensive repair. The Plan denied your request. The Plan says they reviewed the enrollee's records, and they 
show that she has a diagnosis of back pain, problems walking and arthritis in the spine. She was approved for 
an initial power wheelchair. You are requesting additional items for the wheelchair. She does not meet the 
requirements for approval of the wheelchair accessories. 
 
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 wheelchair 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 the enrollee uses a ventilator attached to a 
wheelchair, is at high risk for development of a pressure ulcer. There is no evidence of intermittent 
catheterization. There is no evidence the enrollee is unable to perform a functional weight shift. Her upper 
extremity strength is 5/5 therefore her strength should be sufficient to perform independent pressure relief. The 
physician documentation does not indicate objective evidence of spasticity on a BLE physical exam that needs 
a power seating system for management therefore the request for power tilt and recline exceeds the enrollees 
medical needs. The power elevating leg rests exceeds the enrollee's medical need and does not meet Medicare 
medical necessity criteria.  The documentation does not reveal that the enrollee has leg edema, contractures in 
the lower extremities, inability to flex her knees. The requested power devices are not medically necessary 
therefore the electronic connection and K0108 is not medically necessary. The power seat elevation system is 
not a covered benefit. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of wheelchair accessories have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a power seating system (E1007), an addition to power seating system, power leg 
elevation system (E1010), a power seat elevation system (E2300), an electronic connection between wheelchair 
controller and 2 or more power seating system motors (E2311), an attendant control (K2331) and a wheelchair 
component or accessory, not otherwise specified (K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the CPAP device and supplies provided on 
May 26, 2022. 
 
You asked the Plan to waive the coinsurance for the CPAP device and supplies. You say that the supplies are 
disposable and should not be considered durable medical equipment. The Plan denied your request. The Plan 
says this cost sharing was charged correctly. 
 
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 20% 
coinsurance for durable medical equipment (DME) and related supplies. 
 
 
 
 
 
 You have been asked to pay 20% coinsurance for the CPAP device and supplies. This item/service falls within 
the durable medical equipment (DME) and related supplies 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. The total of the 20% coinsurance for each item is 
$55.78. Therefore, we decided that the Plan does not have to waive the coinsurance for the CPAP device and 
supplies provided on May 26, 2022.
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 needs aggressive physical therapy and 
occupational therapy at IPR level of care to maximize her functional independence to be able to return home at 
discharge. The Plan denied your request. The Plan says IRF admission is not medically necessary and the 
services you need can be provided safely in other settings such as home with home health services or home 
with outpatient therapy. 
 
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 based on the documentation provided, the enrollee does not require the intensity of 
services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of 
rehabilitative services and regular physician evaluation. The enrollees care needs can be met at a lower level of 
care (ex. skilled nursing facility /sub-acute rehabilitation, home health aide). 
 
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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the mental health telehealth visits provided 
on May 11, 2022, to May 13, 2022. 
 
You asked the Plan to waive the copayment for the mental health telehealth visits. You say that you did not 
have any visits on those days. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
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 $30 
copayment for outpatient mental health care telehealth services. 
 
You have been asked to pay a $30 copayment for the mental health telehealth visits. This item/service falls 
within the outpatient mental health care telehealth 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. The records show two telehealth visits for 
medication concerns on May 11, 2022, and May 13, 2022.  Each of these visits incur a $30 copayment, for a total of $60. Therefore, we decided that the Plan does not 
have to waive the copayment for the mental health telehealth visits provided on May 11, 2022, to May 13, 
2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional physical therapy (PT) visits (97164). 
 
You asked the Plan to pre-approve additional PT visits. The Plan denied your request. The Plan says there is no 
clinical evidence to support the medical necessity of this examination or that the enrollee meets Medicare 
criteria for continued PT therapy services. 
 
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 PT 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 the requested therapy is generally accepted as a specific and effective 
therapy for your weakness and impaired balance. However, you have not had a documented significant decline 
in mobility and continue to ambulate using a walker for assistance. Our reviewer found that you also live in a 
long-term care facility and received assistance for mobility and daily activities. Our physician reviewer also 
found that additional PT for improving endurance and balance does not require the services of a skilled 
physical therapist. 
 
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 PT visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve 10 additional physical therapy (PT) visits (97164).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided on April 
18, 2022, to April 20, 2022. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you should not be 
charged a copayment as you do not have a car to get to your appointments. The Plan denied your request. The 
Plan says this cost sharing was charged correctly. 
 
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 $120 
copayment for urgently needed services. 
 
 
 
 
 
 You have been asked to pay a $120 copayment for an emergency room visit. This item/service falls within the 
urgently needed 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. $120 x 2 = $240. Therefore, we decided that the Plan does not have to waive the 
copayment for an emergency room visit provided on April 18, 2022, to April 20, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided on September 16, 2021. 
 
You asked the Plan to pay for physical therapy services. You say that the attached documentation should be 
reviewed, and the claim processed for payment. The Plan denied your request. The Plan says the code is not 
appropriate for the service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the services of a physical therapy assistant (PTA) 
shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they 
do not meet the qualifications of a therapist. 
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of physical therapy services have not been met. Specifically, the billing provider is a nurse 
practitioner, and not a licensed therapist. As such, PTA services cannot be paid incident to this provider's 
professional services. Therefore, we decided that the Plan does not have to pay for physical therapy services 
provided on September 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visit provided on April 06, 
2022. 
 
You asked the Plan to waive the copayment for specialist office visit. You say that this should be covered. The 
Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 $25 
copayment for specialist office visits. 
 
 
 
 
 
 
 You have been asked to pay a $25 copayment for specialist office visit. This item/service falls within the 
specialist office visits 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 specialist 
office visit provided on April 06, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (81455) provided on January 24, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was billed 
with the incorrect date of service. 
 
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 payment for CPT code 81455 is not supported in the medical record. Specifically, the claim 
should be billed with the date the specimen was collected. The records show that the specimen was collected on 
October 6, 2021. As such, the claim was billed with the incorrect date of service. 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 the services (81455) provided on January 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Cala Trio device. 
 
You asked the Plan to pre-approve a Cala Trio device. You say that the services are necessary. The Plan denied 
your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a Cala Trio device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found provided medical visit notes mention the Cala Trio device on September 20, 2022, 
but the visit note goes into no further detail as to why the Cala Trio device is the most appropriate treatment for 
this enrollee at this time. Although there is a signed prescription for the device, the provided medical records 
provide no additional detail supporting the need for the device. 
 
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 Cala Trio device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Cala Trio device.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab work provided on January 06, 2022, to 
May 27, 2022. 
 
You asked the Plan to waive the copayment for lab work. You say that the provider should pay this copayment 
since they ordered the lab work. You have never had to pay for labs before. The Plan denied your request. The 
Plan says this cost sharing was charged correctly. 
 
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 $5 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
 
 
 
 
 You have been asked to pay a $5 copayment for lab work. This item/service falls within the outpatient 
diagnostic tests and therapeutic services and supplies 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. $5 copayment per visit x 4 visits = $20 Therefore, we decided that 
the Plan does not have to waive the copayment for lab work provided on January 06, 2022, to May 27, 2022.
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 not stable on their feet and needs a lot 
of PT that theyre not getting at their current rehab. The Plan denied your request. The Plan says the enrollee 
does not meet the requirements for approval. The services the enrollee needs can be provided safely in their 
current setting. 
 
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 enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. There is no documented need for intensive rehabilitation services and 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 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 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 does not meet 
criteria. 
 
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 pneumonia. The enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an abdominal ultrasound and speech, 
physical and occupational therapy services provided from February 21, 2022, to February 23, 2022. The Plan 
does not have to pay for self-administered drugs provided from February 21, 2022, to February 23, 2022. 
 
You asked the Plan to waive the copayments for an abdominal ultrasound and speech, physical and 
occupational therapy services and to pay for self-administered drugs. You say that the enrollee did not receive 
the services in question. The Plan denied your request. The Plan says the correct cost-sharing was applied and 
that rules for payment for self-administered drugs have not been met. 
 
The Plan does not have to waive the copayment for an abdominal ultrasound and speech, physical and 
occupational therapy services. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay a $40 copayment per service for physical therapy, occupational therapy, and speech language therapy 
and a $110 copayment for basic radiological services when these services are provided at an outpatient 
hospital. 
 
In this case, the case record documents that the enrollee received the services at issue. Therefore, the enrollee 
has been asked to pay a $40 copayment or less per service for speech, physical and occupational therapy 
services and less than a $110 copayment for an abdominal ultrasound. An abdominal ultrasound falls within the 
Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. Speech, physical and 
occupational therapy services fall Outpatient Rehabilitation Services benefit category. This means that the 
enrollee has been asked to pay less than or equal to the correct amounts based on the contract with the Plan. 
This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, 
we decided that the Plan does not have to waive the copayments for an abdominal ultrasound and speech, 
physical and occupational therapy services provided from February 21, 2022, to February 23, 2022. 
 
The Plan does not have to pay for self-administered drugs. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs provided 
from February 21, 2022, to February 23, 2022. 
 
Benefits for self-administered drugs may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.