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

 
We decided that the Plan does not have to pre-approve spinal fusion with insertion of the Vertiflex device. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. 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 the device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found current evidence based medical guideline and peer reviewed literature do not fully support the spinal 
decompression device procedure over the gold standard of lumbar laminectomy. There is a lack of large 
volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollee's medical 
condition as discussed above. FDA indications include implantation of the device at one or two adjacent 
lumbar levels in patients with moderate spinal stenosis in whom operative treatment is indicated at no more 
than two levels, from L1 to L5. This enrollee has MRI findings of mild broad disc bulge L3-4 which in 
combination of moderate degenerative changes of the facets at this level results in minimal relative spinal 
stenosis; mild broad disc bulge L4-5 which in combination of moderate to severe degenerative changes of the 
facets results in mild relative spinal stenosis; mild broad based disc bulge L5-S1 with a small right disc 
protrusion. FDA contraindications include spinal instability, scoliosis, obesity, and osteoporosis, and which 
have not been adequately addressed in the medical records. There is imaging evidence of stable mild 
anterolisthesis of L5 on S1 likely due to facet arthropathy; stable multilevel spondylosis most pronounced at 
L1-2 and L5-S1 along with advanced facet arthropathy in the lower lumbar spine. The imaging does not fully 
document scoliosis (or lack thereof) in the lumbar spine and without documentation of a Cobb angle (if 
applicable.) There is plausible evidence of multiple other spinal level pain generators. Rationale for such a 
replacement device at L4-5 is not fully detailed. There is no discussion indicating that a DEXA scan has 
demonstrated no significant osteoporosis in this patient. Interspinous indirectlumbar decompression would not 
be considered the standard of care for the enrollee's medical condition. Therefore, the intespinous device is not 
medically reasonable or necessary, for treatment of this enrollee's medical condition. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve spinal fusion with insertion of the Vertiflex device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan has to pay for the initial hospital services (99223) provided on December 29, 2019. 
 
You asked the Plan to pay for the initial hospital services. You say that you would like reconsideration because 
these services were rendered by providers with different specialties. The Plan denied your request. The Plan 
says that only 1 initial visit is allowed per hospitalization. 
 
The Plan must follow Medicare rules. Medicare rules say that all physicians (and qualified nonphysician 
practitioners where permitted) who perform an initial evaluation may bill the initial hospital care codes (99221 
 99223). 
 
We find that CPT code 99223 is supported in the record. Specifically, the initial hospital services at issue have 
been validly billed by providers with different specialties. Based on this information, we decided that Medicare 
rules for coverage of the initial hospital services have been met. Therefore, we decided that the Plan has to pay 
for the initial hospital services (99223) provided on December 29, 2019.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Entresto tab 24-26mg for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is a benefit exclusion. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Entresto tab 24-26mg for 
the enrollee.
Appeal type: ER
Decision: Partially Favorable

 
We decided that the Plan has to waive the copayment for the emergency room services. You asked the 
Plan to waive the copayment for the emergency room services. You say that you disagree with the cost share 
applied. The Plan denied your request. The Plan says that the correct cost share amount 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 states that the copayment for 
emergency services may be waived if you are admitted to the hospital.  
 
We looked at your contract with the Plan. We did not see where the contract says in what circumstances the 
copayment for emergency room services may be waived when enrollees are admitted to the hospital. This 
means that the Plan did not follow Medicare rules for disclosure of cost sharing information. Therefore, we 
decided that the Plan has to waive the copayment for the emergency room services.  
 
We also decided that the Plan does not have to waive the copayment for the outpatient hospital visit. You 
asked the Plan to waive the copayment for the outpatient hospital visit. You say that you disagree with the cost 
share applied. The Plan denied your request. The Plan says the correct cost share amount 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 $150 
copayment for outpatient hospital facility visits.  
 
You have been asked to pay a $150 copayment for the outpatient hospital visit. This visit falls within the 
outpatient hospital facility 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 
outpatient hospital facility visit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a prosthetic leg with an advanced foot feature and an 
electronic knee (L5828, L5845, L5848, L5856, L5968, L5981) for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says a request for K3 microprocessor knee and K3 foot does meet Medicare criteria as 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the documentation does not support that the enrollee's functional level requires the requested K3 
microprocessor knee and K3 foot as the requested items appear to exceed the enrollee's medical need and are 
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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a prosthetic leg with an advanced foot feature and an electronic knee (L5828, L5845, 
L5848, L5856, L5968, L5981) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary or rest home visit (99337) provided March 13, 
2019. 
 
You asked the Plan to pay for the domiciliary or rest home visit. You say that the claim was filed on time 
however due to a system glitch it did not process correctly and did not make it to clearinghouse on time. The 
Plan denied your request. The Plan says this claim was submitted past the timely filing limit. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the domiciliary or rest home visit was not filed until July 21, 2020. This 
means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for domiciliary or rest home visit (99337) provided 
March 13, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with accessories. 
 
You asked the Plan to pre-approve the requested Group 3 power wheelchair. You say that the requested type of 
wheelchair is medically necessary. The Plan denied your request. The Plan says the criteria for the requested 
wheelchair are not met. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The 
rules also say that a Group 3 power wheelchair is only covered for those with mobility limitations due to 
certain types of conditions.  
 
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 Group 3 power 
wheelchair. Our reviewer says that the requested Group 3 power wheelchair is not considered reasonable and 
necessary in this case. Our physician reviewer found the patient does have a mobility limitation that impairs 
MRADLs in the home and is not able to be helped by a cane, walker, or manual wheelchair due to decreased 
upper body function. However, the documentation does not reveal that she has a myopathy, neuromuscular 
disorder, or congenital skeletal deformity. 
 
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 Group 3 power wheelchair have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Group 3 power wheelchair with accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services (01920, 99140) provided on August 7, 
2020. 
 
You asked the Plan to pay for anesthesia services. You say that this was medically necessary. The Plan denied 
your request. The Plan says this was not billed with the correct primary diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that the ICD-10-CM has a coding convention that 
requires the underlying condition be sequenced first, if applicable, followed by the manifestation.  Wherever 
such a combination exists, there is a use additional code?note at the etiology code, and a code first note at 
the manifestation code. 
 
We looked at the file and Medicare rules. The billed primary diagnosis, I31.4, is a manifestation code and 
should not be the first billed diagnosis on the claim. Based on this information, we decided that Medicare rules 
for coverage of anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay 
for anesthesia services (01920, 99140) provided on August 7, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency care you received on 
September 12, 2020. 
 
You asked the Plan to waive the copayment. The Plan denied your request. The Plan says you are responsible 
for the copayment. 
 
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 $90 
copayment for each emergency department visit.  
 
Review of the file shows that you were provided emergency room services on September 12, 2020. You have 
been asked to pay a $90 copayment for the services. The services fall within the emergency 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 waive the copayment for the emergency care you received on September 
12, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve fluorodeoxyglucose (FDG) or Axumin positron 
emission tomography (PET) imaging. 
 
You asked the Plan to pre-approve the requested FDG or Axumin PET imaging. You say that this imaging is 
needed to allow for staging of the enrollees disease. The Plan denied your request. The Plan says this is not 
covered by Medicare.  
 
The Plan must follow Medicare rules. Medicare rules say that FDG PET imaging is nationally non-covered for 
initial treatment strategy for newly diagnosed prostate cancer. Medicare rules also indicate that the use of other 
radiopharmaceuticals for oncologic PET imaging can be covered within the local MAC discretion when used 
for their FDA-approved indications.  
 
In this case, it is unclear whether PET imaging using FDG or Axumin is being requested. There is an order for 
Axumin PET imaging, but the Plan made its decision based on FDG PET imaging, which was not refuted by 
the provider's appeal. As such, Maximus has addressed both in its decision.  
 
Medicare nationally non-covers the use of FDG PET imaging for prostate cancer in this circumstance. Imaging 
using of other radiopharmaceuticals, such as Axumin, may be covered. However, the FDA approval for 
Axumin states that "Axumin is a radioactive diagnostic agent indicated for positron emission tomography 
(PET) imaging in men with suspected prostate cancer recurrence based on elevated blood prostate specific 
antigen (PSA) levels following prior treatment." This case is for newly diagnosed prostate cancer. There is no 
suspected recurrence, and there has been no prior treatment. As such, this is not covered as it is not being 
requested for its FDA-approved indication. Therefore, we decided that the Plan does not have to pre-approve 
fluorodeoxyglucose (FDG) or Axumin positron emission tomography (PET) imaging.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound (76536) provided on June 21, 2019, by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the ultrasound. You say that you moved in 2018 and did not know your services 
would not be covered. The Plan denied your request. The Plan says you do not meet criteria for OON coverage 
for the service. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the ultrasound (76536) provided on June 21, 2019, 
by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the tympanic membrane repair services 
(69610) provided December 3, 2020. 
 
You asked the Plan to waive the copayment for the tympanic membrane repair services. You say that the plan 
told you the bill of $65 was because it was out of network. However, you were told by the office that it was 
because it was at an ambulatory surgical center. The Plan denied your request. The Plan says the claim was 
processed, and the correct copayment was applied per the Evidence of Coverage. 
 
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 $65 
copayment for out of network specialist's office visits.  
 
You have been asked to pay $65 for the tympanic membrane repair services. The tympanic membrane repair 
services fall within the Physician/Practitioner services, including doctor's office visits 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 tympanic membrane repair services (69610) provided 
December 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye exam provided on October 6, 2020. 
 
You asked the Plan to pay for the eye exam. You say that you are covered for one eye exam per year. The Plan 
denied your request. The Plan says that these charges are your responsibility. 
 
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 when provided by a Vision Care Provider. 
 
We looked at the file and the Plan's rules. The file indicates you did not receive these services from a Vision Care Provider. Based on this information, we decided that the Plan's rules for coverage 
of the eye exam have not been met. Therefore, we decided that the Plan does not have to pay for the eye exam 
provided on October 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a therapeutic CGM sensor (K0553) provided on September 
8, 2020. 
 
You asked the Plan to pay for a CGM sensor. You say that the requested item is medically necessary. The Plan 
denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. 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 a therapeutic CGM sensor (K0553) provided on September 8, 
2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rocklatan drops for the enrollee. 
 
You asked the Plan to pre-approve the drops. You say that this is medically necessary. The Plan denied your 
request. The Plan says these drops are denied as a benefit exclusion. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Rocklatan drops for the 
enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on 
October 28, 2020 by an OON provider. 
 
You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that the documentation 
says dental is covered at 100%. You also say that you would like to be reimbursed the $100 that you already 
paid your dentist. The Plan denied your request. The Plan says the total $100 amount applied correctly as 
member liability. The Plan also says that cost sharing is a contractual obligation under the Plan and cannot be 
waived. 
 
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 in excess of Medicare coverage, you are responsible for the difference 
between the billed amount and allowed amount for the services rendered OON. Therefore, we decided that the 
Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on October 28, 2020 by an 
OON provider.