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

 
We decided that the Plan does not have to pre-approve a raised toilet seat. 
 
You asked the Plan to pre-approve the seat. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is considered a convenience item. 
 
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 raised toilet seat.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the COVID-19 cleanliness precautions provided on July 23, 
2020. 
 
You asked the Plan to pay for the COVID-19 cleanliness precautions. You say that you received a second 
opinion on the services rendered, and believe the Plan should pay because you feel the second opinion was 
warranted. The Plan denied your request. The Plan says your EOC does not provide a benefit for this service. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
COVID-19 cleanliness precautions provided on July 23, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for testing services provided to the enrollee on May 11, 2020 
and billed under code 95937. 
 
You asked the Plan to pay for this service. You say that this claim should be paid by the Plan. The Plan denied 
your request. The Plan says insufficient medical records were submitted to support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes and provide records that support the services billed.  
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 pay for this service. Our reviewer says that 
Medicare billing criteria are not met. Our physician reviewer found the records provided do not support the 
services billed. The enrollee was billed for code 95937 Neuromuscular junction testing (repetitive stimulation 
paired stimuli), each nerve, any 1 method.   
 
The documentation submitted was reviewed and does not meet criteria or demonstrate this was the service 
performed. We looked at this physician's review, the file, and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan 
does not have to pay for testing services provided to the enrollee on May 11, 2020 and billed under code 95937.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the closed treatment of temporomandibular dislocation 
services coded 21480 provided on May 20, 2020. 
 
You asked the Plan to pay for the closed treatment of temporomandibular dislocation services. You say that 
you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services 
were billed incorrectly. 
 
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 21480 is closed treatment of temporomandibular 
dislocation; initial or subsequent. 
 
We find that CPT code 21480 is not supported in the medical record. Specifically, this code was billed without 
a required anatomical modifier (RT, LT, or 50). Based on this information, we decided that Medicare rules for 
coverage of the closed treatment of temporomandibular dislocation services have not been met. Therefore, we 
decided that the Plan does not have to pay for the closed treatment of temporomandibular dislocation services 
coded 21480 provided on May 20, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan does not have to providecoverage for positron emission tomography (PET) scan for the enrollee.You asked the Plan to providea PET scan. You say that a PET scan is medically necessary for the enrollee.The Plan denied your request. The Plan says Medicare coverage criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated Maximus did not apply the correct criteria.Our Medical Director looked at the reopen and the case file. At issue is coverage for a PET/CT scan. The Maximus Physician Reviewer determined that the single best test for this enrollee with new symptoms, known primary malignancy, currently on chemotherapy, and chronic renal disease would be a PET/CT scan.The Plan requested a reopen and stated that the clinical information available regarding the left arm pain, the lack of documentation of renal disease, and no labs submitted to the plan, the PET/CT scan was appropriately denied as not medically necessary.The medical records show the enrollee is an 83-year-old woman with a diagnosis of micropapillary serous adenocarcinoma of the peritoneum/ovary, as well as diabetes, neuropathy, and kidney failure. Treatment with Arimidex was started in Januaryof 2014. On August 26, 2020, the enrollee complained of new left arm pain. A PET/CT was ordered to ensure no disease progression. No laboratory values are available in the case file. The plan is correct in this case. The documentation is insufficient to demonstrate that the requested PET/CT scan was medically reasonable and necessary for the enrollee in this case. Medicare coverage criteria were not met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a PET scan have not been met.Therefore, we decided that the Plan does not have to providecoverage for positron emission tomography (PET) scan for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 14 Day Sensor. 
 
You asked the Plan to pre-approve a Freestyle Libre 14 Day Sensor. You say that the item is necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that CGM devices are covered when specific criteria is 
met. 
 
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 Freestyle Libre 14 Day Sensor.  
 
 
Our reviewer says that the item is not medically necessary. Our physician reviewer found the enrollee is noted 
to have type III diabetes, for which he takes oral medication, a non-insulin weekly injectable and fixed-dose 
daily insulin. The enrollee already appears to be using a CGM. There is no evidence that the enrollee is using 
the data from the CGM to self-adjust, self-administered doses of insulin multiple times a day. As such, the use 
of CGM is not shown to be medically necessary or reasonable. 
 
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 Freestyle Libre 14 Day Sensor have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a Freestyle Libre 14 Day Sensor.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for durable medical equipment provided by a non-participating provider on May 17, 2019.You asked the Plan to pay for durable medical equipment. You say that you would like the Plan to pay for this. The Plan denied your request. The Plan says that prior authorization was not obtained.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 Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. the Plan has failed to send in a 2019 Evidence of Coverage. Therefore, we decided that the Plan has to pay for durable medical equipment provided by a non-participating provideron May 17, 2019. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a osteogenesis stimulator (E0760). 
You asked the Plan to pre-approve a osteogenesis stimulator. You say that the item is necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
The Plan follows Medicare rules. Medicare rules say that ultrasonic osteogenic stimulators are covered when 
specific criteria is met. 
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 osteogenesis stimulator. Our reviewer 
says that the item is not medically necessary. Our physician reviewer found the documentation does not reveal 
the enrollee had a minimum of two sets of radiographs obtained prior to starting treatment with the osteogenic 
stimulator, separated by a minimum of 90 days or failure or at least one surgical intervention for the treatment 
of the fracture. 
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 osteogenesis stimulator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a osteogenesis stimulator (E0760).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oral appliance for the enrollee. 
 
You asked the Plan to pre-approve an oral appliance. The Plan denied your request. The Plan says that they 
cannot pay a provider who is not eligible to participate in Medicare. 
 
The Plan must follow Medicare rules. The rules state that Medicare payment cannot be made to a supplier who 
is not enrolled in the Medicare Program. 
 
You are not a supplier who is enrolled in the Medicare program. Therefore, we decided that the Plan does not 
have to pre-approve an oral appliance for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary partial upper denture. 
 
You asked the Plan to pre-approve a maxillary partial upper denture (D5213). You say that you need a 
maxillary partial upper denture. The Plan denied your request. The Plan says any services that are over the 
frequency limit are not covered. 
 
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. The Plan covers a maxillary 
partial upper denture (D5213) once per 60 months.  
 
We looked at the file and Medicare rules. The record shows a claim paid on April 6, 2018 for a maxillary 
partial upper denture. Based on this information, we decided that the Plan's rules for coverage of a maxillary 
partial upper denture (D5213) have not been met. Therefore, we decided that the Plan does not have to pre-
approve a maxillary partial upper denture.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan does not have to pre-approve insertion of an interlaminar/interspinous process
stabilization/distraction device for the enrollee.
You asked the Plan to pre-approve this procedure. You say that this procedure is medically necessary. The Plan
denied your request. The Plan says Medical necessity has not been established. Maximus indicated this appeal
was overturned. The Plan requested a reopen stating their appeared to be an error in the review. The Plan is
correct, Maximus upheld the Plans decision. The favorable letter was written in error.
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 this
procedure. Our reviewer says that Medical necessity has not been established. Our physician reviewer found
authorization has been requested for lumbar decompression with Coflex implant at the L4/5 level. In this case,
the FDA indications have not been met in the setting of moderate to severe to severe 3-level spinal stenosis
from L3/4 through L5/S1. Therefore, this request for insertion of an interlaminar/interspinous process
stabilization/distraction device with open decompression (CPT code 22867) would not be considered medically
reasonable and 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 this procedure have not been met. Therefore, we
decided that the Plan does not have to pre-approve insertion of an interlaminar/interspinous process
stabilization/distraction device for the enrollee.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan does not have to provide coverage for positron emission tomography (PET) scan for
the enrollee.
You asked the Plan to provide coverage for a PET scan. You say that a PET scan is medically necessary. The
Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the Plans
denial. The Plan requested a reopen stating Maximus did not apply the correct coverage criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for a PET scan.
The Maximus Physician Reviewer determined that the enrollee had an indication for which a PET scan was
coverable, and that the requested scan was medically necessary and reasonable. The Plan requested a reopen
stating that the enrollee has exceeded the NCD-determined limit of PET scans. The medical records show the
enrollee is a 70-year-old woman with a diagnosis of metastatic adenocarcinoma of the lung. The case file
contains documentation that PET scans were performed on June 19, 2018, December 15, 2018, July 18, 2019,
October 10, 2019, April 14, 2020 and July 7, 2020. The Plan is correct in this case, based on the NCD, which
states "Three FDG PET scans are nationally covered when used to guide subsequent management of anti-tumor
treatment strategy after completion of initial anti-cancer therapy. Coverage of more than three FDG PET scans
to guide subsequent management of anti-tumor treatment strategy after completion of initial anti-cancer therapy
shall be determined by the contractors." There is no further policy for approval of more than three PET scans
for this jurisdiction. Medicare coverage criteria are not met. We looked at this physician's review, the file, and
Medicare rules. Based on this information, we decided that Medicare rules for coverage of a PET scan have not
been met. Therefore, we decided that the Pl
Appeal type: Drugs
Decision: Favorable

We decided that the Plan does not have to pre-approveAkynzeo for the enrollee.You asked the Plan to pre-approveAkynzeo. You say that Akynzeois medically necessary for the enrollee.The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated Maximus did not apply the correct criteria.Our Medical Director reviewed the case file and the reopen request. The Maximus Physician Reviewer determined that Akynzeo is indicated for the prevention of emesis in patients receiving high or moderately emetogenic chemotherapy. This enrollee is planningcarboplatin and etoposide. The dose of carboplatin in this regimen meets criteria for high emetogenic potential, therefore, Akynzeo would be indicated. The Plan requested a reopen stating Aloxi and Emend were approvedfor the enrollee, and notes that the clinical documentation reviewed did not indicate Akynzeo as included in the chemotherapy regimen cycle summary dated June 23, 2020, and in addition the drug has the same therapeutic actions as Aloxi and Emend for individuals receiving neoplastic therapy with moderate to high emetic risk.The medical records show the enrollee has a uterus large cell neuroendocrine carcinoma with transmural invasion, bilateral ovarian, posterior bladder wall involvement and umbilical tissue involvement. The treatment plan included chemotherapy with Carboplatin and Etoposide, immunotherapy with Atezolizumab, and premedication with Aloxi, Dexamethasone, Emend, and Olanzapine. Aloxi (palonosetron) and Emend (aprepitant) were approved on appeal. The request for Akynzeo was denied on appeal. Our Medical Director says that the Plan is correct in this case. It is not clear that Akynzeo is needed in addition to Aloxi and Emend.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Akynzeo have not been met.Therefore, we decided that the Plan does not have to pre-approveAkynzeo for the enrollee.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan does not have to pre-approve Carboplatin, Dexamethasone, and Granisetron IV.
You asked the Plan to pre-approve Carboplatin, Dexamethasone, and Granisetron IV. You say that this drug
combination is medically necessary for the enrollee. The Plan denied your request. The Plan says Medicare
coverage criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated
Maximus did not apply the correct usage criteria. Our Medical Director reviewed the case file and the reopen
request. At issue is coverage for Carboplatin, Dexamethasone, and Granisetron IV. The MAXIMUS Physician
Reviewer determined that the requested use of Carboplatin, Dexamethasone, and Granisetron IV is supported
in a CMS-approved journal. The Plan has requested a reopen citing an error on the face of the evidence. The
Plan has stated that they are unable to identify/locate any support for Carboplatin with Olaparib for the
enrollee's condition. The medical records show the enrollee has a diagnosis of metastatic prostate cancer, as
well as pancreatic cancer and secondary malignant neoplasm of bone. The enrollee has been receiving Olaparib
since March 28, 2019, and Carboplatin since June 30, 2020. Treatment with Carboplatin and Olaparib was
recommended based on Colaris results on January 12, 2017. The enrollee has also received palliative radiation
therapy. The plan is correct in this case. MAXIMUS did not consider the use of Carboplatin in addition to
Olaparib when making this determination. Therefore, Medicare coverage criteria would not be met.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Carboplatin, Dexamethasone, and Granisetron IV have not been met.
Therefore, we decided that the Plan does not have to pre-approve Carboplatin, Dexamethasone, and
Granisetron IV for the enrollee.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan does not have to pre-approve a BiPAP respiratory assist device (E0470).
You asked the Plan to pre-approve this device. You say that this device is medically necessary. The Plan
denied your request. The Plan says Medicare coverage criteria were not met. Maximus overturned the Plans
denial. The Plan requested a reopen and stated that Maximus did not apply the correct Medicare criteria.
Our Medical Director looked at the case file and the reopen request. Our physician reviewer found the Plan is
correct in this case. LCD L33718 provides rules for continued coverage of PAP devices beyond the first three
months of therapy. Clinical benefit needs to be demonstrated by in-person clinical re-evaluation by the treating
practitioner with documentation that symptoms of obstructive sleep apnea are improved, and with objective
evidence of adherence to use of the PAP device, defined as use of PAP 4 or more hours per night on 70% of
nights during a consecutive thirty-day period anytime during the first three months of initial usage. If the above
criteria are not met, continued coverage of a PAP device and related accessories will be denied as not
reasonable and necessary. The medical records do not show all the required criteria are met. We looked at this
physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of this device have not been met. Therefore, we decided that the Plan does not have to pre-approve a
BiPAP respiratory assist device (E0470).
Appeal type: Drugs
Decision: Favorable

We decided that the Plan does not have to pre-approve Herceptin for the enrollee.
You asked the Plan to pre-approve Herceptin. You say that this drug is medically necessary. The Plan denied
your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the Plans denial. The
Plan requested a reopen and stated Maximus did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for Herceptin.
The Maximus Physician Reviewer determined that the NCCN Guidelines Version 2.2020 Endometrial
Carcinoma, and Trastuzumab (intravenous) including biosimilars of trastuzumab: Drug information Copyright
1978-2020 Lexicomp, Inc., support the use of Herceptin in the treatment of endometrial carcinoma. The Plan
has requested a re-opening, citing an error on the face of the evidence. The Plan has stated that they are unable
to identify any support for single agent trastuzumab for the enrollee's condition. The medical records state the
enrollee is a 68-year-old woman with a diagnosis of high-grade serous carcinoma of the uterus, stage 4 IIIC1.
Treatment has included Paclitaxel, Carboplatin, and Trastuzumab. The active plan is maintenance therapy with
Trastuzumab (Herceptin). The Plan is correct in this case. Maximus did not consider the use of single agent
Trastuzumab (Herceptin) in the treatment of carcinoma of the uterus. Medicare coverage criteria are not met.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Herceptin have not been met. Therefore, we decided that the Plan does not have
to pre-approve Herceptin for the enrollee.