Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 hours a day of home health aide services. 
 
You asked the Plan to pre-approve additional home health aide services. You say that additional hours of home 
health aide care are not medically reasonable and necessary. The Plan denied your request. The Plan says the 
criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve additional home health aide services. Our reviewer says that the requested additional hours of home health aide services are not medically reasonable 
and necessary. Our physician reviewer found based on the medical records provided there is no documentation 
that the home health aide services reasonable and necessary to the treatment of the patients illness or injury by 
the skilled professional staff. Provided records do not clarify that the denied three hours per day seven days per 
week are not custodial services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional home health aide services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 8 hours a day of home health aide services.
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 requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 daily 
skilled services are not necessary. Our physician reviewer found clinical documentation by evaluating 
therapists state that the enrollee can receive skilled therapy services on an outpatient or home health level. 
There is no supporting documentation to support daily skilled nursing services, therefore as practical matter, 
the enrollee does not require daily skilled services on in an inpatient basis, in a skilled nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care related to a reverse total 
shoulder arthroplasty. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the requested inpatient care is a 
medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for 
inpatient care have not been met. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.   
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found that detailed documentation is not evident in the case record regarding a 
significant past and/or current/active medical history that would place the enrollee at increased risk for peri-
surgical complications requiring an inpatient stay. There is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception to guidelines. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care related to a reverse total shoulder arthroplasty.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve electronic connection between wheelchair controller and 
two or more power seating system motors (E2311) expandable controller, including all related electronics and 
mounting hardware, upgrade provided at initial issue (E2377) harness upgrade for expandable controller 
(E2313). 
 
You asked the Plan to pre-approve upgraded electronics. You say that you request the denial be reconsidered 
and the power wheelchair with a power tilt and recline seating system be approved so you can provide the 
enrollee with the appropriate medical equipment to meet his medical needs. The Plan denied your request. The 
Plan says the upgraded electronics not medically necessary as the approved power options come with their own 
switches. 
 
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 upgraded electronics. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require a ventilator, or non-proportional input devices (e.g., sip 
and puff, head array, etc.), a separate display (i.e., for alternate control devices), other electronic devices (e.g., 
control of an augmentative speech device or computer through the chair's drive control), or an attendant 
control. The enrollee has power options on the wheelchair but does not need to control the power options 
through a joystick. The enrollee's right upper extremity strength supports that the enrollee can control any 
power options through their own switches. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of upgraded electronics have not been met. Therefore, we decided that the Plan 
does not have to pre-approve electronic connection between wheelchair controller and two or more power 
seating system motors (E2311) expandable controller, including all related electronics and mounting hardware, 
upgrade provided at initial issue (E2377) harness upgrade for expandable controller (E2313).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to adjust the copayment for an inpatient hospital stay provided from 
December 30, 2021, to January 4, 2022. 
 
You asked the Plan to adjust the copayment for the inpatient hospital stay. You say that the facility should have 
only billed for 2 days and not 5 days. The Plan denied your request. The Plan says the provider billed for the 
service that was rendered. Therefore, the proper copayment was applied. 
 
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 $180 
copayment per day, days 1 to 7. The day before you are discharged is your last inpatient day. From December 
30, 2021, to January 4, 2022, there was a total of 6 days with only 5 days being charged a copayment since the 
date of discharge is not chargeable. The total copayment amount for the 5 days was $900 ($180 copayment per 
day x 5 total days). 
 
 You have been asked to pay a $900 copayment for the inpatient hospital stay. The inpatient hospital stay 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. Therefore, we decided that the Plan does not have to adjust the copayment for 
an inpatient hospital stay provided from December 30, 2021, to January 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Lightweight portable motorized/power wheelchair 
(K0012). 
 
You asked the Plan to pre-approve a Lightweight portable motorized/power wheelchair (K0012). You say that 
the requested Lightweight portable motorized/power wheelchair (K0012) is medically necessary. The Plan 
denied your request. The Plan says the requested Lightweight portable motorized/power wheelchair (K0012) is 
not medically necessary. 
 
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 a Lightweight portable 
motorized/power wheelchair (K0012). Our reviewer says that the requested Lightweight portable 
motorized/power wheelchair (K0012) is not medically necessary.  Our physician reviewer found the documentation doesn't specify that the member is unable to accomplish 
mobility related activities of daily living in the home.  There is no physical therapy evaluation to show that the 
member could use this device in the home safely. Furthermore, there is no indication that she couldn't use a 
manual wheelchair or a different assistive device. The requested power wheelchair is 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 a Lightweight portable motorized/power wheelchair (K0012) have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a Lightweight portable motorized/power 
wheelchair (K0012).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on July 12, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this claim has not been billed in 
accordance with Medicare coding regulations. 
 The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided 
that the Plan does not have to pay for the laboratory services provided on July 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided the Plan does not have to provide coverage for retainer crowns (D6750) and pontics (D6240).
You asked the Plan to provide coverage for retainer crowns (D6750) and pontics (D6240). You say that when
they were requested, these dental services were necessary. The Plan denied your request. The Plan says these
dental services were not covered under the Plans dental benefit. Maximus overturned the Plans denial. The Plan
requested a reopen and provided additional information. The Plan states retainer crowns (D6750) and pontics
(D6240) are not covered benefits under the extended dental contract. The Plan also states providers have access
to these benefits and can verify this coverage.
The Plan is correct in this case. 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 more than Medicare coverage, the requested services are not among
those covered under this benefit. Therefore, we decided that the Plan does not have to provide coverage for
retainer crowns (D6750) and pontics (D6240).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable control system. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
enrollee is able to control the approved power options using their own switches. 
 
The Plan follows Medicare rules. Medicare rules say that wheelchair options and accessories are only covered 
under certain medical indications.  
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 requested services. Our physician 
reviewer found that the records document that the enrollee has 5/5 right upper extremity strength and is 
independent with eating, grooming and hygiene thus indicating she has adequate right upper extremity strength 
and function to operate the wheelchair's power options with their own switches. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an expandable control system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the endoskeletal system, above knee or hip 
disarticulation, alignable system (L5920). 
 
You asked the Plan to pre-approve the requested alignable system. You say that this prosthetic item is 
medically reasonable and necessary. The Plan denied your request. The Plan says the requested alignable 
system is not medically reasonable and 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 pre-approve the requested alignable system. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found The  L5920 addition, endoskeletal system, above knee (AK) or hip 
disarticulation, alignable system exceeds the patient's medical need and is not medically necessary per Local Coverage Determination (LCD): Lower Limb Prostheses (L33787) and the Social Security Act, Section 1862 
(a)1(A) and the 42 CFR 411.15(k), as Medicare does not pay for any items or services that are not reasonable 
and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed 
body member. The requested items exceed the patient's medical need as the patient current approved 
preparatory prosthesis is non-alignable and at this time the alignable system is not appropriate for the patient's 
functional 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 the requested alignable system have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the endoskeletal system, above knee or hip disarticulation, alignable 
system (L5920).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the stress test provided by a network 
provider on October 18, 2021. 
 
You asked the Plan to waive the copayment for the stress test. You say that the services should be covered by 
your health plan. The Plan denied your request. The Plan says you have been asked to pay the correct cost-
sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $75 to 
$300 copayment for depending on the Medicare-covered diagnostic radiology services (not including x-rays) 
for CT scan, MRIs, myelography, PET scans, MRA, SPECT, CTA, nuclear cardiology, and stress tests. For this 
date of service, you have been asked to pay the allowed amount of the claim because this amount is less than 
the standard $75 to 300 copayment for the stress test.  
 
 
You have been asked to pay $36.30 copayment for the stress test. The stress test 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. Therefore, we decided that the Plan does not have to waive 
the copayment for the stress test provided by a network provider on October 18, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF 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 there are no comorbid conditions or hospital complications that warrant an acute 
hospital inpatient stay with an inter-disciplinary approach to rehabilitation care or active medical monitoring by 
a physician 3 days per week. There are functional impairments that warrant skilled therapy services for 
impairments in mobility and activities of daily living, however, the enrollee is already having difficulty 
tolerating therapy in a skilled nursing facility level due to lethargy and pain. The enrollee would not be 
expected to tolerate or meaningfully participate in an intense therapy regimen of 3hrs of therapy, 5 days per 
week due to current therapy barriers of lethargy and pain. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a below-knee alignable system (L5910). 
 
You asked the Plan to pre-approve a below-knee alignable system. You say that the requested item is a medical 
necessity for you. The Plan denied your request. The Plan says medical necessity rules for the requested item 
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 below-knee alignable system. Our 
reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the requested item exceeds your medical need as your current approved 
preparatory prosthesis is non-alignable and at this time the alignable system is not appropriate for your current 
preparatory prosthesis. 
 
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 below-knee alignable system have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a below-knee alignable system (L5910).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar spinal fusion. 
 
You asked the Plan to pre-approve lumbar spinal fusion. The Plan denied your request. The Plan says this is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve lumbar spinal fusion. Our reviewer says 
that the requested procedure is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that there is no documented lumbar instability, or nonunion from previous surgery. The criteria 
for lumbar fusion not met. 
 
 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lumbar spinal fusion have not been met. Therefore, we decided that the Plan 
does not have to pre-approve lumbar spinal fusion.