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

 
We decided that the Plan does not have to pay for the non-emergency transportation (A0428) and ground 
mileage (A0425) provided on November 8, 2021. 
 
You asked the Plan to pay for the non-emergency transportation and ground mileage. The Plan denied your 
request. The Plan says despite multiple outreaches by the Health Plan, the treating provider has not submitted 
the clinical records to support the medical necessity of the services. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
 
  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 non-emergency transportation and 
ground mileage. Our reviewer says that the documentation does not support that the ambulance transport on 
November 8, 2021 was medically reasonable and necessary for the enrollee. Our physician reviewer found the 
documentation does not support that other means of transport (such as stretcher van, wheelchair van, taxi, 
private car, or other type of vehicle) were contraindicated for this enrollee. The patient was transferred non 
emergently from a dialysis center to a nursing facility. Our reviewer found while documentation states the 
enrollee was not ambulatory, a stretcher van would have been an appropriate means of transport. Our physician 
reviewer also found that the documentation does not support that the enrollee needed the expertise, services and 
lifesaving and life-sustaining equipment that only a fully-equipped ambulance could provide for safe transport. 
 
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 non-emergency transportation and ground mileage have not been met. 
Therefore, we decided that the Plan does not have to pay for the non-emergency transportation (A0428) and 
ground mileage (A0425) provided on November 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a hospital outpatient clinic visit provided 
from May 24, 2022, to June 14, 2022. 
 
You asked the Plan to waive the copayment for a hospital outpatient clinic visit. You say that you were not told 
that the copayment is $150 and that you would be charged separately for the hospital services. 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 $150 
copayment for outpatient hospital services (including clinic).  
 
  You have been asked to pay $143.88, which is less than the $150 copayment for a hospital outpatient clinic 
visit from May 24, 2022, to June 2, 2022. You were also asked to pay a $150 copayment for a hospital 
outpatient clinic visit on June 14, 2022. These services fall within the outpatient hospital services (including 
clinic) 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 a hospital outpatient clinic visit 
provided from May 24, 2022, to June 14, 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 for the enrollee.
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 that the member is able to get the necessary rehabilitation, such as physical therapy and occupational therapy at the skilled nursing level of care with the goal of safely returning member to home.
Our Medical director looked at the case file and the reopen request. At issues in coverage for IRF admission. Our Medical Director states the documentation does not support that the complexity of the enrollee's nursing, medical and rehabilitation needs required an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our Medical Director found that the enrollee's condition did 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the office visit provided on February 15, 2022.
You asked the Plan to waive the coinsurance for the office visit. You say that you are confused about how and why you owe for the office visit. 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 50% coinsurance for out-of-network Medicare-covered primary care physician (PCP) services. You have been asked to pay a 50% coinsurance for the office visit. This item/service falls within the out-of-network Medicare-covered primary care physician (PCP) 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 coinsurance for the office visit provided on February 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasonic guidance for placement of radiation therapy 
fields (CPT code G6001). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says there is not enough evidence that this type of radiation therapy guidance is needed for 
effective for the enrollee's skin cancer. 
 
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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found billing for daily image-guided radiation therapy (IGRT) or daily simulations (also requested in 
this case) which would not be furnished in accordance with accepted standards of medical practice. 
 
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 pre-approve ultrasonic guidance for placement of radiation therapy fields (CPT code G6001).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the electroencephalogram (EEG); including recording awake and drowsy (95816) provided to the enrollee on October 21, 2021.
You asked the Plan to pay for these services. You say that this service should be covered. The Plan denied your request. The Plan says that the claim processed correctly. The Plan also says that the primary plan's allowable amount is greater than the fee maximum.
The Plan must follow Medicare rules. The rules state that Medicare secondary payment amounts are determined by a formula, and whichever is the lowest.
In this case, the lowest payment is based on the excess of the actual charge minus the primary payment. The record shows that the excess of the actual charge was $155.86. The record shows that they paid $623.46. The remaining payable amount is zero. Therefore, we decided that the Plan does not have to pay for the electroencephalogram (EEG); including recording awake and drowsy (95816) provided to the enrollee on October 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair (K0813). 
 
You asked the Plan to pre-approve the power wheelchair. You say that the power wheelchair is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power wheelchair. Our reviewer 
says that the requested power wheelchair is not medically necessary. Our physician reviewer found the enrollee 
can use a manual wheelchair. There is no evaluation from the requesting physician indicating why a power 
wheelchair is necessary versus a manual wheelchair. 
 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 power wheelchair have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a power wheelchair (K0813).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hospital outpatient clinic visit provided on July 26, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a hospital outpatient clinic visit. You say that you are enclosing documentation 
that supports the timely submission of this claim and are requesting a waiver of the denial and reconsideration 
for payment. The Plan denied your request. The Plan says the enrollee must receive care from a network 
provider. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
The 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 a hospital outpatient clinic visit provided on July 
26, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve a portable ventilator. You say that the records provided support the need for 
a portable ventilator. The Plan denied your request. The Plan says a home mechanical ventilator set in volume-
assured pressure support (VAPS) mode with Auto-EPAP that could be delivered by BiPAP is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 portable ventilator. Our reviewer says 
that the criteria for coverage have not been met. Our physician reviewer found a home ventilator is not 
medically necessary.  The enrollee was recently hospitalized with congestive heart failure (CHF), pulmonary 
edema, and pleural effusions.  The enrollee improved with treatment of the heart failure and BiPAP.  Arterial 
Blood Gas (ABG) was consistent with acute hypercarbic respiratory failure, with pH 7.20 and PaCO2 61.  The pH increased over subsequent days, although PaCO2 remained at 61.  There is no documentation of chronic 
carbon dioxide (CO2) retention with an ABG done while stable as an outpatient, so need for ventilatory support 
as an outpatient is not established.  There does not appear to be a diagnosis of chronic obstructive pulmonary 
disease (COPD.) That diagnosis is not mentioned consistently, and there are no pulmonary function tests.  
There is no diagnosis of neuromuscular disease or thoracic restrictive disease.  Thus, the enrollee does not have 
a diagnosis for which Medicare covers a home ventilator.  If the enrollee does have chronic CO2 retention, 
BiPAP is the appropriate treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a portable ventilator have been met. Therefore, we decided that the Plan does 
not have to pre-approve a portable ventilator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is requires close medical management, 
and therapy for endurance and strengthening. You say that the enrollee is at risk for falling and will need a 
nurse that specializes in rehabilitation. The Plan denied your request. The Plan says an IRF admission is not 
medically necessary, and the enrollee's needs can be met at a lower level of care. 
 
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 complex functional deficits specified that would require intense 
rehabilitation or interdisciplinary team management in an IRF 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay provided on August 
26, 2021, to September 26, 2021. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. 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 $1,925 
copayment for inpatient hospital care. 
 
You have been asked to pay a $1,925 copayment for inpatient hospital stay. This item/service falls within the 
inpatient hospital care 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. You have been asked to pay $385 per day for days 1 through 5 for a total of $1,925. 
Therefore, we decided that the Plan does not have to waive the copayment for inpatient hospital stay provided 
on August 26, 2021, to September 26, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve physical therapy. You say that the practice is only 4.5 miles from your 
home, so it is just as convenient as in-network facilities. You also say you are halfway through your 
rehabilitation with them, and you would like them to be included as an in-network facility. The Plan denied 
your request. The Plan says you must receive your care from a network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
physical therapy to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an advanced microprocessor foot and vacuum socket
system for a prosthetic leg (L5973, L5781).
You asked the Plan to pre-approve these items. You say that this is medically necessary. The Plan denied your
request. The Plan says that Medicare cannot cover a replacement foot when the current foot is still under
warranty.
The Plan must follow Medicare rules. Medicare rules say that the reasonable useful lifetime of equipment in no
case can be less than 5 years.
We looked at the file and Medicare rules. The file indicates you received a prosthetic foot in May of 2021,
which is less than five years ago.
Based on this information, we decided that Medicare rules for coverage of these items have not been met.
Therefore, we decided that the Plan does not have to pre-approve an advanced microprocessor foot and vacuum
socket system for a prosthetic leg (L5973, L5781).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for physician services (93571, 93454, 99232, and 99153) provided to
the enrollee on September 1, 2021.
You asked the Plan to pay this claim. You say that these services should be covered by the Plan. The Plan
denied your request. The Plan says the Medicare billing criteria were not met for code 99153 and codes 93571,
93454 and 99232 were address separately. Maximus upheld code 99153 but partially overturned the Plans
denial for lack of documentation of the outcome of the other codes. The Plan requested a reopen and provided
additional information. The Plan stated codes 93571, 93454, and 99232 were addressed under a separate case
number and overturned for payment at the Plan and paid on May 05, 2022.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate codes. In this case, we are in agreement with the Plan that
code 99153 is not payable and the Plan provided documentation to show codes 93571, 93454, and 99232 we
reprocessed and paid. Therefore, we decided that the Plan does not have to pay for physician services (93571,
93454, 99232, and 99153) provided to the enrollee on September 1, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF)
admission and services for the enrollee.
You asked the Plan to provide coverage for IRF care. You say that at the time of the appeal, IRF admission
was medically necessary. The Plan denied your request. The Plan says the enrollee did not meet the required
criteria for IRF admission. Maximus overturned the Plans denial. The Plan requested a reopen and stated that it
does not appear that Maximus applied the correct criteria.
The Plan is correct in this case. 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. The
Maximus review states the enrollee showed significant decline and required total assistance with toileting,
maximum assistance with lower body dressing and bathing and minimum assistance with upper body dressing.
Therefore, the Plan is correct, the enrollee did not present as a candidate for IRF care or could participate in an
intensive rehabilitation therapy program generally which would consist of at least three hours of therapy per
day at least five days per week. 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 provide coverage for acute
inpatient rehabilitation facility (IRF) admission and services for the enrollee.
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 the medical records provided support the 
need for LTACH care. 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 care needed in another setting. 
 
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 the acute care hospital with unresponsiveness, 
hypotension, acidosis, acute kidney injury, subacute/chronic subdural hematoma, pancreatitis requiring fluids 
as well as bicarabonate, but was complicated by acute respiratory failure requiring intubation, mechanical 
ventilation support, phynylephrine, tracheostomy placement, and percutaneous endoscopic gastrostomy (PEG) 
placement. Recent notes describe the enrollee as being treated for pneumonia, C-diff colitis, and anemia with 
antibiotics and blood transfusion and still dependent on vent support. The enrollee appears to currently be 
unstable and requires short-term additional acute care services that can safely be provided at the current facility until appropriate for transfer. The enrollee does not require services at the LTACH that are not already 
available at the current facility. Transfer to the LTACH is not medically necessary as the enrollee is not yet 
stable for transfer and as it would not be clinically advantageous at this time. Completion of treatment at the 
current facility is 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.