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

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the 
temporomandibular joints. 
 
You asked the Plan to pre-approve an MRI of the temporomandibular joints. You say that an MRI of the 
temporomandibular joints is medically necessary. The Plan denied your request. The Plan says an MRI of the 
temporomandibular joints does not meet the Medicare coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
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 an MRI of the temporomandibular 
joints. Our reviewer says that an MRI of the temporomandibular joints is not medically necessary. Our 
physician reviewer found that in this case, the record indicates that the enrollee has arthralgias of the 
temporomandibular joints bilaterally in the setting of poorly fitting dentures. The record does not indicate that 
conservative treatments have been tried and failed or that dental pathology has been ruled out. The requested 
service is not medically necessary and reasonable for the diagnosis and treatment for the enrollee's clinical 
condition at this time. The elements of the coverage criteria are not satisfied.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of the temporomandibular joints have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an MRI of the temporomandibular joints.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88361, 88312, 88305 and 88104 billed for 
date of service November 12, 2021. 
 
You asked the Plan to pay for procedure codes 88361, 88312, 88305 and 88104. You say that these services 
were medically necessary and are supported as billed. The Plan denied your request. The Plan says these 
services were not billed in accordance with Medicare rules. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that payment is not made under the physician fee schedule for Technical Component (TC) services 
furnished in institutional settings where the TC service is bundled into the facility payment, e.g., hospital 
inpatient and outpatient settings. In addition, TC services furnished by independent laboratories to hospital 
patients are not payable by the MAC. 
 
We find that procedure codes 88361, 88312, 88305 and 88104 are physician pathology services which have 
both professional components (PC) and technical components. These services were not billed with modifier 26 
to indicate that only the professional component payment is requested. This means that payment is requested 
for both the PC and TC of these services. However, these services were provided to an enrollee who was in an 
outpatient hospital setting at the time the sample was collected, which means that the TC component is bundled 
into the facility payment. The TC portion of these services are not separately payable, and therefore these 
services are not supported as billed. Based on this information, we decided that Medicare rules for coverage of 
procedure codes 88361, 88312, 88305 and 88104 have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure codes 88361, 88312, 88305 and 88104 billed for date of service November 12, 
2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for therapeutic exercises, therapeutic 
procedures and ultrasound therapy provided on May 15, 2022. 
 
You asked the Plan to waive the copayment for therapeutic exercises, therapeutic procedures and ultrasound 
therapy. You say that you were hurt there. You also say that when you told the specialist to stop, they did not. 
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 $40 
copayment for occupational therapy/physical therapy/speech therapy at all locations of service.  
 
 You have been asked to pay a $40 copayment for therapeutic exercises, therapeutic procedures and ultrasound 
therapy. This item/service falls within the occupational therapy/physical therapy/speech therapy at all locations 
of service 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 therapeutic exercises, 
therapeutic procedures and ultrasound therapy provided on May 15, 2022.  
 
Maximus read your letter and knows that you may have a quality of care concern. Maximus cannot address 
quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement 
Organization for further review.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a specialist office visit provided on March 30, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for a specialist office visit. You say that the services received on March 30, 2021, 
was by a provider who has been your physician and surgeon for 20 years. The Plan denied your request. The 
Plan says this was not the treatment option (or provider) approved by the Plan, this was not authorized care, 
and this was not a Plan provider. 
 
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 a specialist office visit provided on March 30, 
2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a breast prosthesis, mastectomy sleeve (L8010). 
 
You asked the Plan to pre-approve a breast prosthesis, mastectomy sleeve. You say that you disagree with the 
denial. The Plan denied your request. The Plan says the requested item is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that a mastectomy sleeve is denied as noncovered, 
since it does not meet the definition of a prosthesis.  
 
While a mastectomy sleeve may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
this item. Therefore, we decided that the Plan does not have to pre-approve a breast prosthesis, mastectomy 
sleeve (L8010).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM) 
and supplies (K0553, K0554). 
 
You asked the Plan to pre-approve a Freestyle Libre 2 CGM and supplies. You say that you disagree with the 
denial. The Plan denied your request. The Plan says you do not meet coverage criteria for approval of the 
requested CGM and supplies. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a Freestyle 
Libre 2 CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Freestyle Libre 2 continuous glucose monitor (CGM) and supplies (K0553, K0554).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lymphedema pump sleeve. 
 
You asked the Plan to pre-approve a lymphedema pump sleeve. You say that a lymphedema pump sleeve is 
medically necessary. The Plan denied your request. The Plan says the requested lymphedema pump sleeve does 
not meet the Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules. 
 
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 lymphedema pump sleeve. Our reviewer says that a lymphedema pump sleeve is not medically necessary. Our physician reviewer found 
that the enrollee is a 79-year-old female with a history of hypertension, diabetes mellitus, cardiac issues, 
chronic kidney disease and bilateral lower extremity stage 3 lymphedema. The enrollee has a history of chronic 
kidney disease stage 3B with hospitalization for acute renal failure. The enrollee has followed up with a 
nephrologist and cleared for an intensive phase of lymphedema treatment. The enrollee has not had formal 
treatment for lymphedema but reports she has been trying conservative treatments including elevation, 
compression, and exercise without improvement. The enrollee has found it difficult to tolerate traditional 
compression garments. Physical exam shows bilateral lower extremity edema swollen below the knees and 
impaired skin integrity. There were multiple small bilateral right lower extremity blisters distal to the knee. 
Hyperkeratosis of the skin, right and left lower extremity edema, stage 3 non pitting edema, fibrotic and skin 
changes noted. The enrollee has decreased range of motion, strength, endurance, and sensation of lower 
extremities bilaterally. In this case, there is no documentation of chest, trunk, or abdomen edema. 
Recommendation: manual lymph drainage, multi-layer compression bandaging and therapeutic exercises. The 
enrollee would benefit from inelastic compression garments rather than traditional stockings to improve 
comfort and ease. The review has determined that the requested lymphedema pump sleeve does not meet the 
Medicare LCD coverage criteria. 
 
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 lymphedema pump sleeve have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a lymphedema pump sleeve.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (45385, 45381, 45380) provided on March 
15, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the lab services. You say that you were advised that no authorization was 
required. The Plan denied your request. The Plan says OON services are not covered without prior 
authorization. 
 
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 lab services (45385, 45381, 45380) provided 
on March 15, 2022, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services billed for dates of service May 27, 
2022, to June 24, 2022. 
 
You asked the Plan to pay for home health services. You say that the services at issue were billed correctly. 
The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of home health services have been met. 
Specifically, the case record does not contain documentation of signed physician orders for home health services on the dates of service at issue. Therefore, we decided that the Plan does not have to pay for home 
health services billed for dates of service May 27, 2022, to June 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an intraarticular facet joint injection. You asked the Plan to pre-approve an intraarticular facet joint injection. You say that an intraarticular facet 
joint injection is medically necessary. The Plan denied your request. The Plan says an intraarticular facet joint 
injection does not meet the Medicare coverage criteria. 
 
The Plan follows Medicare rules. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an intraarticular facet joint injection. 
Our reviewer says that the requested intraarticular facet joint injection is not medically necessary. Our 
physician reviewer found this 72-year-old woman has chronic low back pain. The enrollee takes Tramadol, 
Gabapentin and Tizanidine for pain. There is no documentation of recent physical therapy, chiropractic therapy 
or other conservative therapy. There is no documentation of advanced imaging to assess whether there are other 
probable pain generators. No conservative therapy is documented. There is no advanced imaging to assess 
whether the pain is coming from a disc. While intraarticular injections are covered, the outcomes have a lower 
rate of sustained relief compared to a medial branch block and radiofrequency ablation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an intraarticular facet joint injection have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an intraarticular facet joint injection.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a psychiatric diagnostic evaluation with medical assessment 
provided on April 11, 2022. 
 
You asked the Plan to pay for the psychiatric diagnostic evaluation with medical assessment. The Plan denied 
your request. The Plan says the member was enrolled in hospice on this date of service. Traditional Medicare is 
the primary payer. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for a psychiatric diagnostic evaluation with medical assessment 
provided on April 11, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve computed tomography (CT), of the thorax, diagnostic; without 
contrast materials (71250). 
 
You asked the Plan to pre-approve this service. You say that this service is medically necessary for the 
enrollee. The Plan denied your request. The Plan says that the requested service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically 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 this service. Our reviewer says that this 
service is medically necessary. Our physician reviewer found that it is assumed that the enrollee is high risk. 
Thus, a 24 month CT scan is appropriate to ensure a benign etiology of the right lower lobe nodule. If the 
nodule is stable on the 24 month CT scan further surveillance, then a workup is not indicated at that point. 
 
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 been met. Therefore, we decided that the Plan has to pre-
approve computed tomography (CT), of the thorax, diagnostic; without contrast materials (71250).  
 
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 an ultralight wheelchair to include a transit option, 
stroller handles, and side guards for the enrollee. 
 
You asked the Plan to pre-approve a transit option, stroller handles, and side guards. You say that this 
wheelchair and accessories are medically necessary. The Plan denied your request. The Plan says while the 
wheelchair and Medicare allowed accessories were approved, Medicare does not cover a transit option, stroller 
handles, and side guards. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. A transit option, stroller handles, and side guards are not required for use in the home and are 
considered convenience options. Therefore, we decided that the Plan does not have to pre-approve an ultralight 
wheelchair to include a transit option, stroller handles, and side guards for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device 
(E0601) and a humidifier (E0562). 
 
You asked the Plan to pre-approve a CPAP device and humidifier. You say that you had a sleep study done 
with a pulmonologist who advised you need a CPAP machine. The Plan denied your request. The Plan says 
you do not meet the criteria for a CPAP machine. In addition, there is no physician order for a CPAP from your 
primary care physician (PCP) or pulmonologist. 
 
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 physician order, or relevant medical records which support medical 
necessity for the supplies provided in this case. The records also show that your PCP and your pulmonologist 
were contacted, and both confirmed that the requested device was not ordered for you because you do not have 
obstructive sleep apnea. Therefore, we decided that the Plan does not have to pre-approve a continuous positive 
airway pressure (CPAP) device (E0601) and a humidifier (E0562).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of cervical spine 
(72141), MRI of thoracic spine (72146), and MRI of lumbar spine (72148). 
 
You asked the Plan to pre-approve the MRIs. You say that the requested MRIs are medically necessary for the 
enrollee. The Plan denied your request. The Plan says the requested imaging services are not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
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 the MRIs. Our reviewer says that the 
requested MRIs are not medically necessary. Our physician reviewer found the provided documentation 
indicates the enrollee has not had physical therapy within the last 10 years. Therefore, the reviewer found that 
the requested MRIs are not medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the MRIs have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance imaging (MRI) of cervical spine (72141), MRI of thoracic spine (72146), 
and MRI of lumbar spine (72148).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says that the coverage criteria has not been met. 
 
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 clinical documentation shows that the enrollee has functional impairments 
but there are no complex functional deficits specified that would require intense therapy or interdisciplinary 
team management of rehabilitation in an IRF setting. There are no active medical comorbidities listed thus 
would not be expected to require continued inpatient hospitalization in an IRF setting. 
 
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 IRF admission and services.