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

 
We decided that the Plan does not have to pre-approve a power seat elevation system, expandable controller 
with harness upgrade, electronic connection, occupied transit, non-retractable lap belt, and rehab manual 
wheelchair. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. The rules say that an expandable controller is used to control multiple power options. The 
rules say that procedure code K0108 is not to be used to bill for a transit system and related components. The 
rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as 
equipment already available to an enrollee, it is not considered reasonable and necessary. 
 
The requested power seat elevation system and non-retractable lap belt do not serve a purpose that is primarily 
medical in nature. The file shows that the expandable harness is not needed to control the approved power 
switches. The occupied transit was requested with the incorrect procedure code and cannot be covered. The 
rehab manual wheelchair is not needed, as the power wheelchair is approved. 
 
Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system, expandable 
controller with harness upgrade, electronic connection, occupied transit, non-retractable lap belt, and rehab 
manual wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an injection of anesthetic or steroid (64448) and related services provided to the enrollee from April 15, 2021, to April 19, 2021
You asked the Plan to pay for these services. You say that you have provided medical records to support the services at issue. The Plan denied your request. The Plan says that rules for payment have not been met.
The Plan must follow Medicare rules. Medicare rules the submission of a device-intensive procedure also requires that a device be submitted on the same claim/day.
In this case the returned claim does not have the same date of service provided for the device (C1751) as required. Therefore, we decided that the Plan does not have to pay for an injection of anesthetic or steroid (64448) and related services provided to the enrollee from April 15, 2021, to April 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a prosthetic multiaxial ankle (L5986).
You asked the Plan to provide coverage for this advanced prosthetic component. You say that at the time of the appeal this prosthetic component was medically necessary. The Plan denied your request. The Plan says the Medicare coverage criteria were not met. Maximus overturned the Plans denial stating you showed the potential to reach an ambulation level the advanced component would provide. The Plan requested a reopen and stated that the medical records provided at the time of the appeal clearly show you were not being cooperative with rehabilitation after the amputation and that the medical record do not clearly indicate you met the criteria needed for Medicare coverage of the multiaxial ankle which is an advanced component.
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must confirm that Medicare coverage criteria have been met. The rules also say there must be information about the enrollee's history and current condition which supports the designation of the functional level. Based on the medical records provided, the physician and prosthetist notes do not support that you were at a functionality level or a rehabilitative level that met the criteria needed for approval of a multiaxial ankle.
Medicare rules for coverage of this prosthetic component have not been met. Therefore, we decided that the Plan does not have to provide coverage for a prosthetic multiaxial ankle (L5986).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services (procedure codes 00142 and 99100) provided to the enrollee on December 2, 2021.
You asked the Plan to pay for the anesthesia services. You say that this should be paid for. The Plan denied your request. The Plan says procedure code 99100 is considered bundled and not separately payable. The Plan also states that procedure code 00142 should not be reported per the Medicare guidelines.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate procedure code. We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that procedure code 99100 is not separately payable. Procedure code 00142 does not have a global period of 0, 10, or 90 days and therefore should not have been billed with Modifier "-22." Based on this information, we decided that Medicare rules for coverage of the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services (procedure codes 00142 and 99100) provided to the enrollee on December 2, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Tempus Gene Panel provided to the enrollee on January 24, 2022.
You asked the Plan to pay for these services. You say that this will be useful for patients at initial diagnosis, or for a patient with refractory disease. The Plan denied your request. The Plan says that this is not Food and Drug Administration (FDA) approved or cleared as a companion in vitro diagnostic.
Our Medical director looked at the case file and the reopen request. At issue is coverage for the Tempus Gene Panel. Our Medical Director states that the documentation does not support that the coverage criteria for gene testing were met in this case. The Tempus Gene Panel does not have Food & Drug Administration approval or clearance as a companion in vitro diagnostic. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these services. 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 Tempus Gene Panel provided to the enrollee on January 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the co-pay for the specialist office visit provided on May 23, 2022.
You asked the Plan to waive the co-pay for the specialist office visit. You say that you should not be responsible to pay this. 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 co-pay for each Medicare-covered specialty care visit. You have been asked to pay a $40 co-pay for the specialist office visit. This item/service falls within the Medicare-covered specialty care visit 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 co-pay for the specialist office visit provided on May 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the vision services provided on April 3, 2021.
You asked the Plan to pay for the vision services. You say that you sent in all of the required documentation. The Plan denied your request. The Plan says that the required documentation has not been sent into the Plan.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when you submit your bill and documentation of payment. We looked at the file and the Plan's rules. You have not submitted a receipt/bill or documentation of payment. Without this documentation it cannot be determined what the Plan must reimburse. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to pay for the vision services provided on April 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) and supplies for the enrollee.
You asked the Plan to pre-approve a CGM and supplies. You say that the CGM and supplies are necessary. The Plan denied your request. The Plan says that the Medicare rules have not been met.
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 CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) and supplies for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for 12 physical therapy visits for the enrollee.
You asked the Plan to provide coverage for 24 physical therapy visits. You say that 24 additional visits are necessary for the enrollee. The Plan denied your request. The Plan says the enrollee previously had 24 visits. The Plan approved 12 additional visits to transition to home exercise. Maximus overturned the Plans denial. The Plan stated Maximus did not apply the correct criteria.
The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.
Based on the medical records provided at the time of the appeal the Plan approved 12 additional visits to transition the enrollee to home exercise. The records do not show the enrollee met all the required criteria for the 12 remaining visits. Therefore, we decided that the Plan does not have to provide coverage for 24 physical therapy visits for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the $200 copayment charged for outpatient imaging services
provided on November 29, 2021.
You asked the Plan to waive this copayment. You say that you do not believe this copayment is correct. The
Plan denied your request. The Plan says this cost sharing was charged correctly. Maximus overturned the Plans
denial. The Plan requested a reopen and provided additional information to confirm the services provided.
The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all
cost sharing information. Your contract with the Plan clearly says that you must pay $200 copayment for each
advanced imaging service. Computed tomography scans and magnetic resonance imaging are considered
advanced imaging. 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 $200 copayment charged for outpatient imaging services
provided on November 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found a home ventilator is not medically 
necessary. This enrollee has severe obesity and obesity-hypoventilation syndrome. There is no diagnosis of 
chronic obstructive pulmonary disease (COPD), thoracic restrictive disease, or neuromuscular disease. The 
enrollee may benefit from bilevel positive airway pressure (BiPAP) during sleep as an outpatient. Medicare 
does not cover a home ventilator when used as BiPAP, or for the diagnosis of obesity hypoventilation syndrome (OHS). 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the LTACH admission is medically 
necessary. The Plan denied your request. The Plan says criteria for admission to the LTACH have not been 
met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the medical record does not indicate that the enrollee requires services that they 
are not currently receiving but that would be available at the LTACH facility. The elements of the coverage 
rules are not satisfied.  The requested service cannot be recommended. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found the review has determined that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care 
(including earlier emergency department and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the acute inpatient hospital care.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for anesthesia for procedures on the upper abdomen (code 00731) provided 
on July 12, 2022. 
 
You asked the Plan to pay for anesthesia for procedures on the upper abdomen. The Plan denied your request. 
The Plan says that the benefit for this service is included in the payment/allowance for another 
service/procedure that has already been adjudicated. 
 
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. Specifically, the Plan has not provided a rule and the claim remittance that was 
previously adjudicated to substantiate their denial Therefore, we decided that the Plan has to pay for anesthesia 
for procedures on the upper abdomen (code 00731) provided on July 12, 2022.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve an office visit to be provided by OON provider. You say that the services 
are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to 
provide these services. Therefore, coverage criteria have not been met. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve the Group 3 Power Wheelchair with the power tilt and recline options and the power elevating leg rests coded as K0861, E0955, E0956, E1007, E1012, E1028, E2311, E2313, E2361, E2377, E2607, E2620 and K0108.

You asked the Plan to pre-approve the special power wheelchair. You say that you cannot walk at all or use your arms and have a bad back. The Plan denied your request. The Plan says that that the requested power wheelchair exceeds your needs and is not reasonable and necessary, per Medicare criteria.

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. In this case specific records or information was required to substantiate the Plan's denial. The medical records were missing from the original case file. A request for the medical records was sent to the Plan January 12, 2023, with a due date of January 19, 2023. As of the date of this letter, the Plan has not responded to our request and/or submitted the required information. Therefore, we decided that the Plan has to pre-approve the Group 3 Power Wheelchair with the power tilt and recline options and the power elevating leg rests coded as K0861, E0955, E0956, E1007, E1012, E1028, E2311, E2313, E2361, E2377, E2607, E2620 and K0108.

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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Optimizer Smart device. 
 
You asked the Plan to pre-approve an Optimizer Smart device. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has 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 an Optimizer Smart device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found while the clinical studies led to FDA approval in 2019, cardiac contractility 
modulation (CCM) remains the subject of multiple studies examining long-term efficacy, as well as 
randomized, controlled, double-blinded trials to quantify clinical efficacy. Until such statistically rigorous 
studies are completed, it is premature to presume clinical outcomes and benefit. At the current time, the CCM 
system is not considered to be medically necessary in this enrollee. 
 
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 Optimizer Smart device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an Optimizer Smart device.