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

 
We decided that the Plan does not have to pay for the knee ligament repair (27405) provided on August 18, 
2021. 
 
You asked the Plan to pay for the knee ligament repair (27405). You say that CPT code 27405 was paid and 
then payment was recouped. You say that you want clarification of the denial. The Plan denied your request. 
The Plan says procedure code 27405-51 is not supported by the medical records submitted. 
 
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 27405 is repair, primary, torn ligament and/or capsule, 
knee; collateral. 
 
  We asked our coder 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 the knee ligament repair (27405). Our reviewer says that the 
documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found that 
the operative report does not describe a primary collateral repair per the policy manual. In this case, CPT 27405 
repair of torn ligament cannot be confirmed as performed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the knee ligament repair (27405) have not been met. Therefore, we decided that 
the Plan does not have to pay for the knee ligament repair (27405) provided on August 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental 
gradient appliance (E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that the item is medically 
necessary. The Plan denied your request. The Plan says the member does not have lymphedema extending onto 
the chest, trunk and/or abdomen. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and segmental gradient appliance (E0667).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided from September 21, 2021, 
through October 29, 2021. 
 
You asked the Plan to pay for physician's services. You say that this physician was previously your husband's 
cardiologist, and you contacted this physician after you had a heart attack. The Plan denied your request. The 
Plan says the services were obtained out-of-network and were not authorized. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided from September 21, 2021, through 
October 29, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar facet radiofrequency ablations (RFAs). 
 
You asked the Plan to pre-approve lumbar facet RFAs. You say that your chronic excessive pain is detrimental 
to health. The Plan denied your request. The Plan says the denial of authorization for this service is correct, 
because the incorrect procedure was requested. 
 
The Plan follows Medicare rules. Medicare rules state that facet joint interventions may be covered if certain 
criteria are 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 lumbar facet RFAs. Our reviewer says 
that you do not meet the Medicare criteria for the requested radiofrequency ablations. Our physician reviewer found you have documented radiculopathy and responded to selective nerve root block. Therefore, this request 
is not 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 lumbar facet RFAs have not been met. Therefore, we decided that the Plan does 
not have to pre-approve lumbar facet radiofrequency ablations (RFAs).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair power seat elevation system (E2300). 
 
You asked the Plan to pre-approve a wheelchair power seat elevation system. You say that the item is 
medically necessary. The Plan denied your request. The Plan says this item is not primarily medical in nature. 
 
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 wheelchair power seat elevation system (E2300).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the NeoTYPE Analysis Colorectal Profile rendered on 
October 28, 2021. 
 
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 the services were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular pathology is covered when specific 
criteria are 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 pay for these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the enrollee has abdominal 
carcinomatosis with malignant ascites from adenocarcinoma of the colon. The available clinical documentation 
in the case file does not support that the testing will directly impact the treatment or management of the 
enrollee in this case. It has not been shown that the number of genes or tests are reasonable and necessary to 
establish a diagnosis. The documentation is insufficient to demonstrate that the targeted genomic sequence 
analysis was medically reasonable and necessary for the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. 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 NeoTYPE Analysis Colorectal Profile rendered on October 28, 2021.  
 
Local Coverage Article (LCA) A56199 referenced by the Plan is for the incorrect jurisdiction and was not used 
in the MAXIMUS determination.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pharmacogenomic panel testing provided on September 
23, 2021. 
 
You asked the Plan to pay for the pharmacogenomic panel testing. You say that this claim should be 
reprocessed based on the medical records. The Plan denied your request. The Plan says this testing has not been 
billed correctly per Medicare coding regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules say that if a laboratory procedure 
produces multiple reportable test results and there is no procedure code that describes the procedure, the lab 
must report a miscellaneous/unlisted procedure code with a single unit of service.  
We looked at the file and Medicare rules. This lab testing was not billed as required by coding regulations. 
Based on this information, we decided that Medicare rules for coverage of the pharmacogenomic panel testing 
have not been met. Therefore, we decided that the Plan does not have to pay for the pharmacogenomic panel 
testing provided on September 23, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the imaging services (93976, 76870) provided on November 
28, 2021. 
 
You asked the Plan to pay for the imaging services. You say that you would like this claim reprocessed based 
on the medical documentation. The Plan denied your request. The Plan says the claim has denied correctly as 
the documentation does not support the additional units billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
We find that the additional billed units are not supported in the medical record. The medical record only 
supports the services that have already been paid. Based on this information, we decided that Medicare rules 
for coverage of the imaging services have not been met. Therefore, we decided that the Plan does not have to 
pay for the imaging services (93976, 76870) provided on November 28, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Imfinzi (J9173). 
 
You asked the Plan to pre-approve Imfinzi. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says the requested drug is not approved by the FDA for the enrollee's diagnosis. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Imfinzi. Our reviewer says that the 
requested drug, Imfinzi, is not medically necessary. Our physician reviewer found the Food and Drug 
Administration (FDA) has not stated that the requested drug is indicated for the enrollee's condition. The 
Medicare approved cancer drug compendia do not contain a supportive citation for the use of the requested 
drug in the enrollee's clinical situation. The reviewer found there is no literature from Medicare approved 
cancer journals were submitted for review. Therefore, the reviewer found that the requested drug, Imfinzi, is 
not medically reasonable or necessary in this case. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Imfinzi have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Imfinzi (J9173).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shoulder orthosis (L3650) provided on December 22, 
2021. 
 
You asked the Plan to pay for the shoulder orthosis. You say that this equipment should be paid for based on 
the medical documentation. The Plan denied your request. The Plan says the documentation does not support 
payment for the services as billed. 
 
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 relevant medical records which support medical necessity for the supplies provided in this case. In this case, the documentation does not feature the provider discussing with the enrollee the 
medical necessity of the provided shoulder orthosis. 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 the shoulder orthosis (L3650) provided on December 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for the crown - porcelain/ceramic 
(D2740) and maxillary partial denture - cast metal framework with resin denture bases (including 
retentive/clasping materials, rests and teeth) (D5213) provided November 30, 2021. 
 
You asked the Plan to provide additional payment for the crown and upper partial denture. You say that the 
dental provider billed more for the services than they originally estimated. The Plan denied your request. The 
Plan says the upper partial denture is not covered under your benefits. Your remaining dental benefit for 2021 
was applied to the crown. 
 
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.  
We reviewed the file and Medicare rules. The Plan provided documentation showing that at the time the crown 
was provided you had $813 remaining in your annual dental maximum. This amount was applied toward the 
cost of the crown. 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 provide additional payment for the crown - porcelain/ceramic (D2740) and maxillary partial denture - cast 
metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) (D5213) 
provided November 30, 2021.  
 
Your complaint about the network provider charging more than they originally estimated for the services is not 
a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the 
Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a premium intraocular lenses for the cataract surgery. 
 
You asked the Plan to pre-approve a premium intraocular lenses for the cataract surgery. You say that the 
service is medically necessary. The Plan denied your request. The Plan says the refractive-correcting 
functionality of an IOL does not fall into the benefit category and is not covered. 
 
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives a P-C IOL 
during cataract surgery, the enrollee will be responsible for the difference in cost between the P-C IOL and a 
conventional IOL. Although presbyobia-correcting IOLs may serve the same function as eyeglasses or contact 
lenses furnished following cataract surgery, IOLs are neither eyeglasses nor contact lenses. Therefore, the 
presbyopia-correcting functionality of an IOL does not fall into the benefit category and is not covered. 
 
While a P-C IOL may be appropriate for you, neither the Plan nor Medicare covers the presbyopia-correcting 
feature of a P-C IOL. Therefore, we decided that the Plan does not have to pre-approve a premium intraocular 
lenses for the cataract surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a radiofrequency ablation procedure of the lumbar facet 
joint (64635, 64636). 
 
You asked the Plan to pre-approve a radiofrequency ablation of the lumbar facet joint. You say that the 
requested procedure is a medical necessity for you. The Plan denied your request. The Plan says medical 
necessity rules for the requested procedure have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a radiofrequency ablation of the lumbar 
facet joint. Our reviewer says that the requested services are not considered medically reasonable and necessary 
in this case. Our physician reviewer found that the requirement is for 2 sets of diagnostic blocks which provide 
greater than 80% pain relief. According to the available records, this requirement has not been fulfilled. 
 
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 radiofrequency ablation of the lumbar facet joint have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a radiofrequency ablation procedure of the 
lumbar facet joint (64635, 64636).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided September 30, 
2021. 
 You asked the Plan to pay for the orthosis. You say that say the medical records provided support the necessity 
of the services in dispute. The Plan denied your request. The Plan says the services are not supported in the 
medical records received. 
 
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 pay for the orthosis. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found lumbar-sacral orthosis are indicated for: postsurgical support of traumatic fractures, 
spondylolisthesis, scoliosis, spinal stenosis, herniated disks, and disk infections. There is no specific clinical 
rationale for the requested spinal stenosis. The review has determined that the medical records provided do not 
meet the requirements listed in the LCD for Medicare coverage. 
 
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 orthosis have not been met. Therefore, we decided that the Plan does not 
have to pay for the lumbar-sacral orthosis (L0650) provided September 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crutch substitute (E0118). 
 
You asked the Plan to pre-approve a crutch substitute. You say that the item is medically necessary. The Plan 
denied your request. The Plan says this is not a covered item. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the knee scooter have not been met. Specifically, this item is not a covered benefit of Medicare or 
the Plan. Therefore, we decided that the Plan does not have to pre-approve a crutch substitute (E0118).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital care services (99223) provided on June 28, 2021. 
 
You asked the Plan to pay for the hospital care services. You say that you would like this claim reprocessed 
based on the medical documentation. The Plan denied your request. The Plan says coverage for an additional 
unit of this hospital care is not supported in the medical documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
We find that an additional unit of CPT code 99223 is not supported in the medical record. The medical record 
only supports 1 units of CPT code 99223. There is no medical information provided in the file that 2 hospital 
visits were provided on the date in question. Based on this information, we decided that Medicare rules for 
coverage of the hospital care services have not been met. Therefore, we decided that the Plan does not have to 
pay for the hospital care services (99223) provided on June 28, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that the records provided support the need for SNF 
care. The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says 
that the enrollee can receive the care needed in another setting. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found there is no documentation that the 
patient requires skilled nursing services. The records do not document the need for intravenous medications, 
new tube feeding, or ostomy care or daily complex wound care. The medical records do demonstrate that the 
enrollee requires skilled therapy services. However, these services are not required on a daily basis. The 
enrollee is walking household distances with a two-wheeled walker with stand-by assistance and is independent 
for transfers. The provided records do not document a significant decline in the enrollees functional status to 
necessitate daily inpatient skilled therapy services. The enrollee does not require the services on an inpatient 
basis, only in a skilled nursing facility setting. The records do not document that services in an assisted living 
facility with home health care or in a long-term care facility on a part time basis are not appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.