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

 
We decided that the Plan does not have to pre-approve a home ventilator system. 
 
  You asked the Plan to pre-approve a home ventilator system. You say that the enrollee has chronic obstructive 
lung disease, chronic respiratory failure, oxygen dependent, and obstructive sleep apnea. You say that the 
Life2000 will provide the enrollee with the ventilatory support they require. The Plan denied your request. The 
Plan says a home ventilator is not medically necessary for this patient because their needs can be met with an 
alternative device such as a BiPAP device with average volume-assured pressure support (AVAPS).  
 
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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and necessary. 
 
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 home ventilator system. Our reviewer 
says that a home ventilator system is not medically necessary. Our physician reviewer found that the enrollee 
has severe comorbidities and requires very specialized care to deal with those issues which seem to have 
caused them respiratory compromise. The enrollee's arterial blood gas was reviewed, in addition, to all data and 
labs, and there is no indication that home ventilator is require for best practice. The enrollee may or may not 
benefit from a BiPAP but requires closer attention to their other comorbidities which likely caused the 
exacerbation. 
 
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 home ventilator system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a home ventilator system.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist services rendered on
November 22, 2022.

You asked the Plan to waive the copayment for these services. You say that the copayment is a financial
hardship. 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 $45
copayment for in-network office visits to specialists.

Review of the file shows that you received specialist physician services on November 22, 2022. The previous
determination stated that the Plan did not support that the services had been rendered; however, the original
case file contains the Claim Summary for the services at issue. Per the contract with the Plan, there is a $45
copayment for in-network office visits to specialists. However, the Medicare approved amount for these
services was $9.18. Given that the allowed amount was less than the $45 copayment, you have been asked to
pay $9.18 for these services. 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 specialist
services rendered on November 22, 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 LTACH services. You say that the enrollee needs LTACH services. The 
Plan denied your request. The Plan says the enrollee does not meet the requirements for an LTACH admission. 
 
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 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 is receiving appropriate care in the current acute care setting as provided 
by the Plan. The documentation provided does not support that LTACH services are medically appropriate at 
this time. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of LTACH services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve LTACH services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on June 21, 
2023. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you disagree with the 
copayment. 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 $350 
copayment for ambulance services. 
 
You have been asked to pay a $350 copayment for ambulance services. This item/service falls within the 
ambulance services benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance services 
provided on June 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for wound dressing provided on July 14, 
2023. 
 
You asked the Plan to waive the coinsurance for wound dressing. You say that the bill is too high. 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 wound dressing. 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. Therefore, we decided that the Plan does not have to waive the 
coinsurance for wound dressing provided on July 14, 2023.
Appeal type: Testing
Decision: Unfavorable

We decided the Plan does not have to waive the copayment for the stress test rendered on November 22, 2022.

You asked the Plan to waive the copayment for these services. You say that you disagree with the charges. 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 $75
copayment for each covered diagnostic procedure or test at a network doctor's office. Review of the file shows
that you received a stress test on November 22, 2022. The previous determination stated that the Plan did not
support that the services had been performed; however, the original case file contains an Explanation of
Benefits (EOB) for this claim and the Plan also forwarded new documentation of the medical records for the
date of service at issue. You have been asked to pay a $75 copayment for these services.

This service falls within the each covered diagnostic procedure or test at a network doctor's office 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 rendered on November 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on August 16, 2023, billed 
with procedure code 99152-59. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed code. 
 
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 99152-59 is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older.  
We asked our coder 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 practitioner services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found there is a more specific code that should 
be reported when moderate sedation is administered for a gastrointestinal endoscopic procedure. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on August 16, 2023, billed with procedure code 
99152-59.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the traction equipment (E0849) provide don June 8, 2023. 
 
You asked the Plan to pay for the traction equipment. You say that the item was medically necessary. The Plan 
denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. There is no indication this item was needed, discussed, or ordered in the clinical documentation submitted. The record shows that the Plan made several attempts to obtain the necessary documentation 
without success. Therefore, we decided that the Plan does not have to pay for the traction equipment (E0849) 
provide don June 8, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids provided on August 8, 2023. 
 
You asked the Plan to pay for hearing aids. You say that you needed the hearing aids and thought you could go 
to any provider. The Plan denied your request. The Plan says hearing aids purchased outside of the Plans 
nationwide network are not covered. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased through the nationwide network. 
.  
We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of hearing aids have not been met. Specifically, the hearing aids were purchased outside of the 
nationwide network. Therefore, we decided that the Plan does not have to pay for hearing aids provided on 
August 8, 2023.
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 denial of medical coverage for an 
LTACH level of care will seriously jeopardize the member's life, health, and ability to regain function. You 
also say a skilled nursing facility will not provide adequate physician, nursing and therapy coverage and care 
for the member's current health disposition. The Plan denied your request. The Plan says the member is 
receiving appropriate in-patient acute care and is currently unstable for transfer to an LTACH. 
 
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  that these services are able to be obtained at the acute care hospital where the 
enrollee is currently receiving care. Our physician reviewer also found that the enrollee does not require 
transfer to another facility to obtain this care. The enrollee does not require transfer to another facility to obtain 
this 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided the Plan does not have to provide coverage for a lower extremity prostheses, flex-walk system or
equal (L5981) for the enrollee.

You asked the Plan to provide coverage for a lower extremity prosthesis, flex-walk system or equal (L5981).
The Plan denied your request. The Plan says the Medicare coverage criteria are not met. Maximus overturned
the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria. The
Plan noted that the requested foot is a Blatchford Echelon coded as L5981. This foot has a maximum weight
limit of 275 pounds. At the time of the appeal, the enrollee weighed 281 pounds which exceeds the safety
capacity for the requested foot.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that items and
services that are not medically necessary or medically appropriate are not covered. Based on the medical
records, the enrollee exceeded the maximum weight requirement for the requested accessory. The
manufacturing specs for this accessory show the weight limit is 275 pounds. Therefore, we decided that the
Plan does not have to provide coverage for a lower extremity prostheses, flex-walk system or equal (L5981) for
the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fluid circulating cold pad with pump (E0218). 
 
You asked the Plan to pay for the fluid circulating cold pad with pump (E0218) will be denied as not 
reasonable and necessary. You say that the item was medically necessary. The Plan denied your request. The 
Plan says the item was not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a fluid circulating cold pad with pump (E0218) 
will be denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the fluid circulating cold pad with pump (E0218) will be denied as not reasonable and necessary. 
have not been met. Therefore, we decided that the Plan does not have to pay for the fluid circulating cold pad 
with pump (E0218).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a duplex scan provided on June 10, 2023. 
 
You asked the Plan to pay for a duplex scan. You say that you are requesting reconsideration for the denied 
claim. The Plan denied your request. The Plan says with the information they have, they cannot determine how 
the enrollee came to the servicing provider, whether the services were performed as billed, or whether the 
services are medically necessary. 
 
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 a duplex scan have been met. No supporting medical records were submitted to prove that the services billed on this claim actually occurred. 
Therefore, we decided that the Plan does not have to pay for a duplex scan provided on June 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for routine foot care provided on June 27, 2023. 
 
You asked the Plan to pay for routine foot care. You say that you are requesting reconsideration for the denied 
claim. The Plan denied your request. The Plan says you did not meet the medical necessity criteria for podiatry 
services. 
 
The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is 
for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or 
feet or have fungal nails.  
 
Records do not show that any of these conditions are present. The services you are asking the Plan to pay for 
are routine foot care services. Based on this information, we decided that Medicare rules for coverage of 
routine foot care have not been met. Therefore, we decided that the Plan does not have to pay for routine foot 
care provided on June 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve optimizer smart implantable pulse generator. 
 
You asked the Plan to pre-approve optimizer smart implantable pulse generator. You say that you are 
requesting reconsideration for the denied claim. The Plan denied your request. The Plan says it is not medically 
necessary due to insufficient evidence of efficacy. 
 
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 optimizer smart implantable pulse 
generator. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the subject of multiple studies examining long-term 
efficacy, as well as randomized, controlled, double-blinded trials to quantify clinical efficacy. Until such 
statistically rigorous studies are completed, it is premature to presume clinical outcomes and 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 optimizer smart implantable pulse generator have not been met. Therefore, we 
decided that the Plan does not have to pre-approve optimizer smart implantable pulse generator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311), expandable controller 
harness (E2313), and expandable controller (E2377). 
 
You asked the Plan to pre-approve an electronic connection, expandable controller harness, and expandable 
controller. You say that Medicare has reviewed, approved, and found it medically necessary and covered. You 
also say that the Plan should follow Medicare's decision. The Plan denied your request. The Plan says the 
electronic connection, expandable controller harness, and expandable controller cannot be covered as it is not 
medically necessary to control the three requested power options through the joystick (drive interface). 
 
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 an electronic connection, expandable 
controller harness, and expandable controller. 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 
document that the enrollee has 5 out of 5 bilateral upper extremity strength and is independent with eating thus 
indicating they have adequate upper extremity strength and function to operate the wheelchairs 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 an electronic connection, expandable controller harness, and expandable 
controller have not been met. Therefore, we decided that the Plan does not have to pre-approve an electronic 
connection (E2311), expandable controller harness (E2313), and expandable controller (E2377).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 6 fractions of intensity modulated radiation therapy 
(IMRT). 
 
You asked the Plan to pre-approve 6 fractions of IMRT. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says it is recommended to have this requested service 
once daily IMRT course. 
 
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 6 fractions of IMRT. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this treatment is not within accepted standards of care, and the appeal provided no 
supporting literature relevant to this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 6 fractions of IMRT have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 6 fractions of intensity modulated radiation therapy (IMRT).