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

 
We decided that the Plan does not have to pre-approve a custom fabricated prosthesis identified with code 
L8035. 
 
You asked the Plan to pre-approve a custom fabricated prosthesis. You say that the only option you have left is 
prostheses. The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a custom fabricated prosthesis is not covered. 
 
We looked at the file and Medicare rules. Review of the file shows that you are requesting a custom fabricated 
prosthesis. This item is specifically not covered. Based on this information, we decided that Medicare rules for 
coverage of a custom fabricated prosthesis have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a custom fabricated prosthesis identified with code L8035.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care services (99291) provided on February 22, 2022, 
and February 23, 2022. 
 
You asked the Plan to pay for critical care services (99291). You say that the documentation supports the 
evaluation and management level of care billed and the code is payable as billed. The Plan denied your request. 
The Plan says the documentation submitted does not support a critical care visit of 30-74 minutes was 
performed. 
 
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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
  We find that CPT code 99291 is not supported in the medical record. Specifically, the records do not document 
the time spent on critical care services as required by the CPT code billed. Based on this information, we 
decided that Medicare rules for coverage of critical care services (99291) have not been met. Therefore, we 
decided that the Plan does not have to pay for critical care services (99291) provided on February 22, 2022, and 
February 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee orthosis. 
 
You asked the Plan to pre-approve a knee orthosis. You say that the enrollee suffers with bilateral knee pain. 
The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested item. 
 
The Plan must follow Medicare rules. Medicare rules say that knee orthoses are covered when the enrollee has 
had recent injury to or a surgical procedure on the knee(s) or the enrollee has knee instability. 
. 
 We looked at the file and Medicare rules. Review of the file shows that the enrollee has a diagnosis of knee 
pain. The documentation does not support that the enrollee has had a recent injury, a recent surgical procedure 
on the knee, or knee instability. This means the enrollee does not meet criteria for the requested item. Based on 
this information, we decided that Medicare rules for coverage of a knee orthosis have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a knee orthosis.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda for the enrollee.
You asked the Plan to pre-approve the requested treatment. You say that this drug is medically necessary. The Plan denied your request. The Plan says the requested dosing treatment is not covered by Medicare. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for Keytruda. The Maximus Physician Reviewer determined that the enrollee has head and neck right maxillary sinus cancer. Keytruda at 400 mg intravenously every six weeks in combination with carboplatin and 5-FU is considered a standard dose for a patient with head and neck cancer. The Plan requested a reopen and argues that there is no established evidence to support the use of Keytruda (in combination with carboplatin and 5-FU) to be dosed at 400 mg every 21 days for 5 cycles for non-nasopharyngeal metastatic squamous cell H&N cancer. The Plan approved coverage for Carboplatin 750mg every 3 weeks, Fluorouracil 7000mg every 3 weeks and Keytruda 200mg every 3 weeks (or 400mg every 6 weeks). The Plan denied the request for Keytruda 400mg every 3 weeks because the dosing requested is higher than recommended.
The Plan is correct in this case. The provider did not submit sufficient justification for the requested Keytruda dosing of 400 mg every three weeks for this enrollee. The requested dosing regimen is not supported in the Medicare approved drug compendia. Therefore, 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 the requested treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda for the enrollee.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyaluronan or derivative, Synvisc or Synvisc-One, for 
intra-articular injection (CPT code J7325). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says there is no documentation that it is medically necessary for you to be treated with this non-preferred agent. The Plan states there is no documentation that you have tried a preferred agent or why 
a preferred agent cannot be used. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 medication. Our physician reviewer 
found the Plan requires a trial of drug Durolane, Euflexxa, Supartz, and GelSYN-3 before they will approve the 
requested drug. In this case, you have not tried and failed the required drug(s). There is no documentation 
provided indicating that the Plans required drug(s) would likely be less effective and/or likely have adverse 
effects for you. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Hyaluronan or derivative, Synvisc or Synvisc-One, for intra-articular injection (CPT code 
J7325).
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that criteria for admission to a SNF have not been met. 
The Plan denied your request. The Plan says that the enrollee needs rehabilitation to be able to get strong 
enough to care for herself. 
 
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 care. Our reviewer says that SNF 
care is medically reasonable and necessary. Our physician reviewer found that the enrollee requires the level of 
observation, evaluation and treatment provided by a physician in the skilled nursing facility setting. The 
enrollee requires monitoring for adequate perfusion of her lower extremity as well as continued wound care. 
The enrollee also does require the level of intensity of skilled therapy services provided in the skilled nursing 
facility setting. The enrollee currently requires minimum to moderate assistance with transfers and bed 
mobility. The enrollee requires daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled 
nursing facility (SNF) 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 SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for Supartz.
You asked the Plan to provide coverage for Supartz. You say that Supartz 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 that Maximus did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for Supartz. Maximus
determined that the contract with the Plan does not support that step therapy criteria have been implemented for
the health plan in which the enrollee was enrolled.
Therefore, the Plan did not show that the enrollee was contractually obligated to try Euflexxa or Durolane before Supartz. The Plan disagreed with the Maximus determination and submitted their step therapy criteria.
The medical records show a diagnosis of Bilateral primary osteoarthritis of the knees. The Plan is correct in this
case. The documentation does not support that Euflexxa or Durolane would be less likely to result in adverse effects for you. We looked at this physician's review, the file, and Medicare rules. Based on this information,
we decided that Medicare rules for coverage of Supartz have not been met. Therefore, we decided that the Plan
does not have to provide coverage for Supartz.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aubagio. 
 
You asked the Plan to pre-approve Aubagio. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
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 Aubagio.  
 
Benefits for Aubagio may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the total hip arthroplasty (CPT code 27130). 
 
You asked the Plan to pre-approve the total hip arthroplasty. You say that the services are necessary. The Plan 
denied your request. The Plan says the request does not meet criteria for medical necessity because there is no 
documentation of joint pathology confirmed by imaging and no attempts at conservative treatment/failure of 
conservative treatment were established. 
 
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 total hip arthroplasty. Our physician 
reviewer found detailed documentation is not evident regarding trial and failure of recent, reasonable, and 
comprehensive less invasive conservative care measures. Moreover, there were no diagnostic imaging studies 
provided or noted to corroborate the left hip pathology. Therefore, 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 total hip arthroplasty have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the total hip arthroplasty (CPT code 27130).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve these services. You say that the enrollee's current scooter will not fit in the 
transportation lift to allow him to go to medical appointments. The Plan denied your request. The Plan says the 
services are not covered. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a power scooter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair. 
 
You asked the Plan to pre-approve a power wheelchair. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that a power wheelchair is being requested for use in a SNF or hospital. Therefore, we decided 
that the Plan does not have to pre-approve a power wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injection services (procedure code J3490) provided to the 
enrollee on October 26, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says procedures should be reported with the most comprehensive code that describes the services 
performed. 
 
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 J3490 is "Unclassified drugs." 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that in this case, there was a more 
comprehensive code to report for the services documented. The unclassified drug Healthcare Common 
Procedure Coding System (HCPCS) code cannot be verified. 
 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for injection services (procedure code J3490) provided to the enrollee on October 26, 2021.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you are appealing the denied services with medical 
records. The Plan denied your request. The Plan says that the submitted documentation does not show that the 
enrollee needs daily and regular skilled nursing care. The enrollee needs a controlled environment. There is no 
evidence that the enrollee needs SNF level of care, and their needs can be met at a long-term care facility. 
 
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 care. Our reviewer says that that 
the requested SNF care is considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the clinical documentation shows that the enrollee has several comorbidities that 
would require the assessment and monitoring by a skilled nurse. Clinical documentation shows that the enrollee 
has functional deficits and evaluating skilled therapists recommend daily skilled therapy in a skilled nursing 
facility. From a practical purpose daily skilled services on an inpatient basis in a skilled nursing facility is 
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 SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 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 compression garment identified with code A4465. 
 
You asked the Plan to pre-approve the requested item. The Plan denied your request. The Plan says Medicare 
does not cover this item. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A4465 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve a compression 
garment identified with code A4465.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the enrollee from August 23, 2021, to September 13, 2021.
You asked the Plan to pay for this claim as billed. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial for insufficient information in the case file regarding the denial. The Plan requested a reopen and provided additional documentation. The Plan demonstrated that this claim denied because the provider has billed this service inappropriately. The claim was inappropriately billed with "EACB1". The Plan states the correct patient driven payment model (PDPM) should have billed as "EAID". The claim provided shows the errors billed.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In July 2018, CMS finalized a new case-mix classification model, the Patient Driven Payment Model (PDPM), that, effective beginning October 1, 2019, will be used under the Skilled Nursing Facility (SNF) Prospective Payment System (PPS) for classifying SNF patients. Based on the records provided, this claim was not billed with the appropriate PDPM code. Medicare rules for coverage of this claim as billed have not been met. Therefore, we decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the enrollee from August 23, 2021, to September 13, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transcatheter mitral valve implantation- valve in valve 
(using an Edwards Sapien 3 device) (CPT code 0483T). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the clinical value and effectiveness of transcatheter mitral valve implantation in the 
setting of low to intermediate surgical risk persons has not been demonstrated by the Food and Drug 
Administration (FDA) or in peer-reviewed literature. The Plan states that more research is needed to show 
safety and efficacy of the procedure. 
 
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 items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation is inadequate to confirm fulfillment of published Centers for Medicare & 
Medicaid Services (CMS) guidelines for transcatheter mitral valve replacement (TMVR). As a result, at this 
time TMVR would not be considered medically reasonable and necessary in this enrollees clinical 
management. 
 
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 transcatheter mitral valve implantation- valve in valve (using an Edwards Sapien 3 device) 
(CPT code 0483T).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantable neurostimulator (CPT code(s): L8769 and 
64555). 
 You asked the Plan to pre-approve the implantable neurostimulator. You say that the device is for the 
enrollees back pain. The Plan denied your request. The Plan says this is not a covered benefit by Medicare for 
your condition. 
 
The Plan must follow Medicare rules. Medicare rules say that payment may be made for implanted peripheral 
nerve stimulators in which electrodes are surgically placed under the skin around a nerve. The rules also say 
that acupuncture is only covered when provided for low back pain when furnished by a licensed acupuncturist.    
 
We looked at the file and Medicare rules. We find that this device does not meet the Medicare definition for an 
implanted nerve stimulator because the device involves needles inserted around the nerves and not electrodes 
being surgically implanted. The Food and Drug Administration (FDA) clearances for devices of this type are as 
electro-acupuncture devices. Since acupuncture is not covered by Medicare for any condition when rendered 
through a device rather than by a licensed practitioner, we find that Medicare coverage criteria for this auricular 
stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve implantable 
neurostimulator (CPT code(s): L8769 and 64555).