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

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service October 18, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that 76641 should be covered because multiple 
services were rendered on the same day for the enrollee. The Plan denied your request. The Plan says this code 
is included in the facility payment and is not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the radiologist. 
 
The records indicate that this service was provided to the enrollee while an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code 76641. This means there 
is both a professional and technical component for the CPT code. In this case, an appropriate modifier to 
indicate the professional component has not been billed with CPT code 76641. Although 76641 was billed with 
modifier 50, this is not adequate indication of the professional component of the service. Based on this 
information, we decided that Medicare rules for coverage of procedure code 76641 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 76641 billed for date of service 
October 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics.  
 
You asked the Plan to pay for foot orthotics. You say that you would like reconsideration because the requested 
foot orthotics are medically necessary. The Plan denied your request. The Plan says this item is not a covered 
benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of 
orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pay for foot 
orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 standard power wheelchair with multiple 
power options (K0861), harness (E2313), expandable controller (E2377), and additional items and accessories 
(codes E0953, E0955, E1007, E1012, E1028, E2300, E2361 x2, E2607, E2620, and K0040 x2). 
 
You asked the Plan to pre-approve a group 3 standard power wheelchair and additional items and accessories. 
The Plan denied your request. The Plan says the enrollee does not have a medical need for multiple power 
options included with a K0861 group 3 power wheelchair. The Plan also says an expandable controller and 
expandable controller harness cannot be covered as it is not medically necessary to control the three requested 
power options through the joystick (drive interface). 
 
The Plan follows Medicare rules. Medicare rules say that a power mobility device (PMD) will not be covered if 
the patient does not have mobility deficit that impairs their participation in Mobility-Related Activities of Daily 
Living (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. The rules also say if the PWC base is not 
covered, then related accessories will be denied. 
 
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 group 3 standard power wheelchair 
and additional items and accessories. Our reviewer says that the enrollee does not meet the criteria for 
coverage. Our physician reviewer found the enrollee has cerebral palsy and is non ambulatory. The enrollee has 
used a wheelchair chronically and is able to transfer independently. Our reviewer also found that the enrollee 
does not have high risk for skin breakdown, use a catheter intermittently, have spasticity or require an 
alternative means of managing power drive. 
 
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 group 3 standard power wheelchair and additional items and accessories have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 standard power 
wheelchair with multiple power options (K0861), harness (E2313), expandable controller (E2377), and 
additional items and accessories (codes E0953, E0955, E1007, E1012, E1028, E2300, E2361 x2, E2607, 
E2620, and K0040 x2).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466) and durable medical 
equipment (DME), miscellaneous (E1399). 
 
 
 You asked the Plan to pre-approve a home ventilator and DME miscellaneous. You say that the enrollee has 
COPD with chronic respiratory failure. The enrollee's carbon dioxide level was still critically high while 
utilizing a BIPAP, which would require a ventilator with alarm capabilities, volume support and battery backup 
which cannot be provided with any BIPAP machine at home. The Plan denied your request. The Plan says the 
request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that 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 and DME 
miscellaneous. Our reviewer says that the service is not medically necessary. Our physician reviewer found the 
enrollee has COPD, heart failure with reduced ejection fraction (HFrEF), obstructive sleep apnea, and 
obesity. The enrollee was recently hospitalized with an exacerbation of COPD and heart failure, and arterial 
blood gas (ABG) was consistent with acute on chronic hypercarbic respiratory failure.  There is no diagnosis of 
thoracic restrictive disease or neuromuscular disease. There are no pulmonary function tests to assess the 
severity of the COPD. This enrollee may benefit from BiPAP with average volume assured pressure support 
(AVAPS) during sleep as an outpatient. Medicare does not cover a home ventilator when used at settings that 
can be provided with BiPAP. 
 
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 and DME miscellaneous have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a home ventilator (E0466) and durable medical equipment 
(DME), miscellaneous (E1399).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services. 
 
You asked the Plan to pre-approve the dental services. You say that this dental work is medically necessary. 
The Plan denied your request. The Plan says dental services from an out-of-network provider are not covered 
by your supplemental benefits.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
You are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested items or services are not covered under this benefit when received 
from an out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve dental 
services.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve brachytherapy services. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says that the 
requested service is investigational. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The case file sent to us for this appeal was incomplete. The case file did not include the initial authorization 
request, the Plans initial denial, the reconsideration request, or any medical records that the Plan used in 
making their decision. Maximus made multiple attempts to obtain additional information with no success. The 
Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request.  Therefore, we decided that the Plan has to pre-approve brachytherapy services.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
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 LTACH facility stay is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet the criteria 
for an LTACH facility stay. 
 
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 appears to be improving with current treatment and should only require 
short-term additional acute care services that can safely be provided at the current facility until more stable and 
appropriate for transfer to a lower level of care soon.  
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from January 26, 2023, to 
February 22, 2023. 
 You asked the Plan to pay for the home health services. You say that you attempted to timely file the NOA, but 
it was rejected.  You claim that the Plan does not have adequate communication with providers attempting to 
get credentialing. The Plan denied your request. The Plan says the NOA was not received timely. As such, this 
final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is December 27, 2022. The NOA was not received by the Plan until March 3, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from January 26, 2023, to February 22, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from October 4, 2022, to 
November 2, 2022. 
 You asked the Plan to pay for the home health services. You say that you believe the NOA was submitted 
timely. The Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim 
was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is October 4, 2022. The NOA was not received by the Plan until January 18, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from October 4, 2022, to November 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodic oral evaluation (D0120) and cone beam- less than 
one whole jaw (D0380) provided on November 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the periodic oral evaluation was exhausted on date of service June 9, 2022. Therefore, we decided that the Plan does not have to pay for periodic oral evaluation (D0120) and cone beam- less than 
one whole jaw (D0380) provided on November 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the specialist visits provided from March 23, 
2022, to May 3, 2023. 
 
You asked the Plan to reimburse you for the specialist visits. You say that you had a cervical cancer screening 
and screening pap smear. 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 $35 
copayment for Physician/practitioner services.  
 
You have been asked to pay a $35 copayment for each specialist visit. These services fall within the 
Physician/practitioner 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. Additionally, the record shows that you did not pay a cost sharing amount for 
the preventive pap and pelvic exams. Therefore, we decided that the Plan does not have to reimburse you for 
the specialist visits provided from March 23, 2022, to May 3, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from March 16, 2023, to 
April 14, 2023. 
 You asked the Plan to pay for the home health services. You say that you attempted to submit the NOA on 
March 20, 2023, but it was rejected due to a tax ID issue. The Plan denied your request. The Plan says a valid 
NOA has not been received, so this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, a valid NOA has not been received by the Plan. As a result, no payment can be made on this claim. 
Therefore, we decided that the Plan does not have to pay for home health services provided from March 16, 
2023, to April 14, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an addition to lower limb prosthesis, vacuum pump, 
residual limb volume management and moisture evacuation system (L5781). You asked the Plan to pre-approve a vacuum pump. You say that the enrollee is now a bilateral amputee and 
has previously used a vacuum pump with his previous prosthesis. The Plan denied your request. The Plan says 
experimental items and items that are not shown to be safe and effective cannot be covered. 
 
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 vacuum pump. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the use of an L5781 vacuum assisted suspension system for residual limb volume management 
and moisture evacuation systems among lower extremity amputees is unproven and not medically necessary 
due to insufficient evidence of safety and/or efficacy. The physician documentation does not support the need 
for the elevated vacuum suspension system. The requested is not medically necessary per 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. 
 
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 vacuum pump have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an addition to lower limb prosthesis, vacuum pump, residual limb volume management 
and moisture evacuation system (L5781).
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 cannot function by himself and needs 
the intensive rehab. The Plan denied your request. The Plan says the IRF services you are requesting do not 
meet the requirements for approval. 
 
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 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee has demonstrated significant physical 
decline, and they will only begin to make improvement once intensive therapy begins. The Plan denied your 
request. The Plan says admission to an IRF is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of the enrollees nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy 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 an IRF admission and services.