Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided to the enrollee on October 3, 2019. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Medicare requires use of CPT 81479 to report a Guardant360 molecular pathology genomic 
profiling for NSCLC. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare 
rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay 
for lab services provided to the enrollee on October 3, 2019.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services billed to the enrollee from February 13, 
2020 to March 16, 2020. 
 
You asked the Plan to pay for home health services billed to the enrollee. You say that this claim should be 
paid. The Plan denied your request. The Plan says the HIPPS code is not valid and the RAP claim denied 
because of the error with the HIPPS code. The Plan states that code 1CGL1 is not a valid code. The Plan 
states a corrected claim would be reviewed if submitted.  
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. We looked at the claim submitted, the file and the 
Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home 
health services have not been met. Specifically, the code billed 1CGL1 has been inactive since December of 
2019. Therefore, we decided that the Plan does not have to pay for home health services billed to the enrollee 
from February 13, 2020 to March 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the parenteral nutrition solution rendered on February 5, 
2018 to February 9, 2018. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code B4185 is not supported. 
 
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 B4185 is parenteral nutrition solution, not otherwise 
specified, 10 grams lipids. 
 
We find that CPT code B4185 is not supported in the medical record. Specifically, the records do not support 
the billing of seven units of the code. Based on this information, we decided that Medicare rules for coverage 
of these services have not been met. Therefore, we decided that the Plan does not have to pay for the parenteral 
nutrition solution rendered on February 5, 2018 to February 9, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the requested physician's services. 
  
You asked the Plan to pre-approve the physician's services to be provided. The Plan denied your request. The 
Plan says that the services are available with a network neurologist who specializes in neuromuscular 
conditions.  The services are not emergent or urgent. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the 
requested physician's services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a walk-in shower (K1003). 
 
You asked the Plan to pre-approve a walk-in shower. You say that you need this due to your limited mobility. 
The Plan denied your request. The Plan says this item does not serve a medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a walk-in shower (K1003).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.
You asked the Plan to pre-approve the additional trips. You say that this is medically necessary. The Plan
denied your request. The Plan says you cannot request additional trips past the available trips.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this
case. The Plan covers a maximum of 24 one-way trips per year.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that you have five trips remaining in your benefit. There is no benefit for additional trips beyond 24 per year.
Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to a vascular surgeon. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary for reevaluation to 
determine other treatment options. The Plan denied your request. The Plan says the medical records do not 
show symptoms causing functional impairment, or response to medical treatment such as leg elevation and/or 
compression stockings. 
 
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 referral. Our reviewer says that the 
requested referral is not considered medically reasonable and necessary in this case. Our physician reviewer 
found you have already been seen by a vascular surgeon. No other vascular issues have been identified. You 
have already undergone left greater saphenous vein closure. There is no documentation that you are having 
persistent, lifestyle limiting symptoms despite the regular use of compression stockings. There is no 
documentation that you have had a new event since the last vascular evaluation. Lower greater saphenous vein 
ablation will not reduce the risk of a stroke. 
 
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 referral have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a referral to a vascular surgeon.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sensors for use with a  non-therapeutic continuous 
glucose monitor (CGM) (A9276). 
 
You asked the Plan to pre-approve sensors. You say that this has been covered in the past and is necessary to 
monitor your blood sugar. The Plan denied your request. The Plan says this is not covered under Medicare 
rules. 
 
The Plan must follow Medicare rules. Medicare rules say that CGM devices that do not meet the definition of a 
therapeutic CGM as defined in CMS Ruling 1682R will be denied as non-covered. Code A9276 describes the 
supplies used with a non-therapeutic CGM. 
 
We looked at the file and Medicare rules. The requested supplies are for use with a non-covered CGM. Based 
on this information, we decided that Medicare rules for coverage of sensors have not been met. Therefore, we 
decided that the Plan does not have to pre-approve sensors for use with a  non-therapeutic continuous glucose 
monitor (CGM) (A9276).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continued stay at the SNF. 
 
You asked the Plan to pre-approve the continued SNF stay. You say that you would like more time in the SNF 
because the muscle tone in your legs are still too weak, and this puts you at risk for falls. The Plan denied your 
request. The Plan says SNF care beyond 100 days per benefit period is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that you received 100 days of SNF care during the benefit period from March 26, 2020 to July 
28, 2020. The Plan has covered 100 days of SNF care. 
 
Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. You will be eligible for a new benefit period when you have not been 
receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the 
Plan does not have to pre-approve a continued stay at the SNF.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 power wheelchair. 
 
You asked the Plan to pre-approve power wheelchair. You say that you are appealing with records. The Plan 
denied your request. The Plan says the denial of authorization for this item is correct, because a power operated 
vehicle has not been ruled out as an appropriate option for the enrollee. 
 
The Plan follows Medicare rules. Medicare rules say that a power wheelchair is covered when certain clinical 
criteria have been met, including that the enrollee does not meet the criteria for a power operated vehicle. 
 
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 power wheelchair. Our reviewer says 
that the enrollee does not meet the Medicare criteria for the requested power wheelchair. Our physician 
reviewer found based on the medical records provided, there is no documentation that a power operated vehicle 
(such as a scooter) has been ruled out as an appropriate option for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of power wheelchair have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Group 2 power wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endovenous ablation therapy. 
 
You asked the Plan to pre-approve endovenous ablation therapy. You say that you are appealing with records. 
The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the 
enrollee has not failed 3 months of conservative treatment. 
 
The Plan follows Medicare rules. Medicare rules say that surgical treatment of varicose veins is covered for 
certain clinical 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 endovenous ablation therapy. Our 
reviewer says that the enrollee does not meet the Medicare criteria for the requested endovenous ablation 
therapy. Our physician reviewer found the documentation does not demonstrate that the enrollee has failed a 3-
month trial of conservative therapy or that there were any efforts at conservative treatment. Additionally, there 
is not satisfactory documentation that the enrollee's symptoms are severe enough to impair mobility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of endovenous ablation therapy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve endovenous ablation therapy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay the full cost for lenses. 
 
You asked the Plan to pay the full cost for the lenses. You say that you feel that the allowance should be $300 
or more. The Plan denied your request. The Plan says there is only a $40 allowance for these services. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services with an allowance up to $40 per year. 
 
We looked at the file and the Plan's rules. The plan can only pay for $40 worth of this request, per your 
contract. The plan cannot pay the full amount for your lenses. Based on this information, we decided that the 
Plan's rules for coverage of the lenses have not been met. Therefore, we decided that the Plan does not have to 
pay the full cost for lenses.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IUD. 
 
You asked the Plan to pre-approve the IUD. You say that you would like reconsideration because the member 
is not a candidate for hormonal birth control. The Plan denied your request. The Plan says Medicare does not 
cover birth control devices and procedures. 
 
The Plan must follow Medicare rules. The rules say that items/services for the purposes of preventing 
conception (contraception) are not considered medically reasonable and necessary.  
 
Records show that the requested service is primarily for the purpose of contraception. The documentation does 
not show that this service is being requested to treat a specific illness/injury. As such, the Medicare rules for 
coverage of this item/service have not been met. Therefore, we decided that the Plan does not have to pre-
approve an IUD.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to provide a high frequency chest wall oscillation device. 
 
You asked the Plan to provide a high frequency chest wall oscillation device. You say that there is a clinical 
indication for this therapy to be considered. The Plan denied your request. The Plan says the enrollee does not 
meet the criteria for a high frequency chest wall oscillation device. 
 
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases. 
 
The record does not show that the enrollee has cystic fibrosis, bronchiectasis, or a covered neuromuscular 
disease. This means that the enrollee does not have a medical condition for which a high frequency chest wall 
oscillation devise can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to 
provide a high frequency chest wall oscillation device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transcutaneous electrical nerve stimulation (TENS) 
unit. 
 
You asked the Plan to pre-approve the TENS unit. You say that the records should support the necessity of the 
service in dispute. The Plan denied your request. The Plan says the records do not support that the enrollee 
meets the Medicare criteria for the device. 
 
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 TENS unit. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has a diagnosis of fibromylagia and ongoing low back pain. Documentation does 
not support the enrollee has an approved diagnosis. Additionally, the documentation does not support the 
enrollee is participating in an approved clinical study. Without the support of the documentation, medical 
necessity cannot be determined. The denial is upheld. 
 
We looked at this physician's review, the file, and Medicare rules.  Please note that our decision is only about 
your Medicare benefits. This service has been approved for coverage under Medicaid. Maximus does not have 
jurisdiction with regard to Medicaid benefits. Based on this information, we decided that Medicare rules for 
coverage of the TENS unit have not been met. Therefore, we decided that the Plan does not have to pre-
approve a transcutaneous electrical nerve stimulation (TENS) unit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you have a growth on your left foot, arthritis 
and flat feet. 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 you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the requested physician's services. 
 
You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says out-of-
network services, unless emergent in nature or not available within the medical group network, are not 
considered medically necessary 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the 
requested physician's services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the requested lumbar back brace. 
 
You asked the Plan to pre-approve the lumbar back brace. The Plan denied your request. The Plan says you 
must receive care from in-network providers with the exception of emergency or urgent care, dialysis while 
temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which 
requires prior authorization from the plan. 
 
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 item at issue in this appeal. We found no exception that would require the Plan 
to pre-approve this item. Therefore, we decided that the Plan does not have to pre-approve the requested 
lumbar back brace.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two fixed partial denture sectionings (D9120 x2). 
 
You asked the Plan to pre-approve the fixed partial denture sectionings. You say that it is necessary to section 
off the cantilever portion of tooth #'s 2 & 15, in order to save the teeth. The Plan denied your request. The Plan 
says this service is not covered under the enrollee's plan. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve two 
fixed partial denture sectionings (D9120 x2).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electric connection with expandable controller and 
harness for a Group 3 power wheelchair (PWC). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that an electric connection with expandable controller and 
harness are covered when specific criteria are met. 
 
We looked at the file and Medicare rules. The electric connection with expandable controller and harness are 
not covered because the approved PWC has only one power option. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an electric connection with expandable controller and harness for a Group 3 power 
wheelchair (PWC).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture and a complete 
mandibular denture. 
 
You asked the Plan to pre-approve the complete maxillary denture and complete mandibular denture. You say 
that your previous dentures were accidentally thrown away. You also say that you have not had teeth for over 6 
months, and you are in pain when trying to chew. The Plan denied your request. The Plan says these services 
are allowed one time every 60 months. The Plan also says that you received dentures less than 60 months ago. 
 
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, dentures are limited to one set every 5 
years. The record shows that you received a complete maxillary denture and a complete mandibular denture on 
July 6, 2017 and your dentures benefit has been exhausted. Therefore, we decided that the Plan does not have 
to pre-approve a complete maxillary denture and a complete mandibular denture.