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

We decided that the Plan does not have to provide coverage for a Group 3 Power wheelchair for the enrollee.
You asked the Plan to provide coverage for a Group 3 Power wheelchair. You say that the requested power
wheelchair is medically necessary. The Plan denied your request. The Plan says the requested power
wheelchair exceeds the enrollees needs and cannot be safely operated by the enrollee. Maximus upheld the
Plans denial. Maximus then reopened the case to confirm exactly which type of power wheelchair had been
requested. The Plan confirmed a Group 3 Power wheelchair was requested.
The Plan is correct in this case. The Plan follows Medicare rules. Medicare rules say that all criteria listed in
the Medicare Rules section must be met for coverage. 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 for a
Group 3 Power wheelchair. Our physician reviewer found the enrollee is totally dependent for mobility and
self-care. The medical records show the enrollee is unable to operate the requested power wheelchair and the
physical therapy evaluation has recommended a safer, manual wheelchair that will assist with her
mobility. Therefore, the Medicare coverage criteria are not met since the Medicare rules state the evaluation
must clearly support the equipment requested.
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 Group 3 Power wheelchair have not been met. Therefore, we decided that the
Plan does not have to provide coverage for a Group 3 Power wheelchair.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel provided on August 8, 2021. 
 
You asked the Plan to pay for the services provided. You say that the panel detects genomic alterations. The 
Plan denied your request. The Plan says the testing is not FDA approved. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
 We find that the gene panel was billed with multiple codes. If a single procedure is performed, only one code 
with one unit of service may be reported for the procedure. Based on this information, we decided that 
Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan 
does not have to pay for the gene panel provided on August 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames (V2020) and sphere, single vision, plano to plus 
or minus 4.00, per lens (V2100) provided January 7, 2022. 
 You asked the Plan to pay for the frames and lenses. You say that you should be free to use your vision benefit 
when you need it. The Plan denied your request. The Plan says you are not eligible for a new vision allowance 
until after November 9, 2022. 
 
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 a $200 vision allowance for routine contact lenses or eyewear every year. This 
benefit is administered on a rolling calendar year since your last date of service. 
 
We looked at the file and the Plan's rules. The Plan provided documentation showing that your vision 
allowance was used on November 9, 2021. Based on this information, we decided that at the time your routine 
eyewear was purchased on January 7, 2022, your vision allowance had been exhausted. Therefore, we decided 
that the Plan does not have to pay for the frames (V2020) and sphere, single vision, plano to plus or minus 
4.00, per lens (V2100) provided January 7, 2022.  
 
Your complaint about the way the Plans benefits are written and restrictions on when you can use your 
benefits 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) of the lower extremity 
without contrast material (73700). 
 
You asked the Plan to pre-approve a CT scan. You say that the enrollee has failed all conservative treatment 
options and requires a CT scan to proceed with other treatment options. The Plan denied your request. The Plan 
says the requested CT is not medically necessary in this case. The criteria for coverage of this imaging service 
are not met, and this scan is requested solely to perform robotic assisted knee replacement which is an 
investigational procedure. 
 
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 a CT scan. Our reviewer says that the 
requested imaging service is not medically necessary and reasonable in this case. Our physician reviewer found 
that the enrollee is being treated for bilateral knee osteoarthritis. She presented with bilateral knee pain and 
mild genu varus alignment to both knees. However, there is limited published, large-scale, long-term peer-
reviewed literature that shows this request to be an effective and/or safe treatment for the noted pathology. 
Overall improved long term functional improvement and/or pain relief have not been documented with the CT 
scan, in this clinical setting. There is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. Therefore, the requested CT of the lower 
extremity without contrast material, in this case, is not medically reasonable or 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 a CT scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve computed tomography (CT) of the lower extremity without contrast material (73700).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive periodontal exam (code D0180) you 
received on February 16, 2022. 
 
You asked the Plan to pay for the comprehensive periodontal exam. You say that this service should be covered 
because you are at risk for jaw osteonecrosis. The Plan denied your request. The Plan says this is not a covered 
service under your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Your dental benefit only 
covers those services explicitly listed in your dental benefits chart.  Comprehensive periodontal exams are not 
listed as covered services, meaning that they are not covered for any reason. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
comprehensive periodontal exam (code D0180) you received on February 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that you need this device due to your chronic obstructive 
pulmonary disorder (COPD). The Plan denied your request. The Plan says the denial of authorization for this 
device is correct, because a ventilator is not covered by Medicare for this purpose and your needs can be met 
by a positive airway pressure (PAP) device instead. 
 
The Plan must follow Medicare rules. Medicare rules say that a ventilator is not covered when used to provide 
positive airway pressure therapy, regardless of the underlying medical condition.  
 
We looked at the file and Medicare rules. A ventilator is not covered by Medicare for this purpose. The Plan 
says that they would approve a positive airway pressure (PAP) device upon request. Please contact the Plan for 
more information about your treatment options. Based on this information, we decided that Medicare rules for 
coverage of ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
portable ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on March 4, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the service is medically necessary. The Plan denied 
your request. The Plan says enrollee's must receive care from in-network providers. 
 
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 office visit provided on March 4, 2022 by an 
out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Leqvio. 
 
You asked the Plan to pre-approve Leqvio. The Plan denied your request. The Plan says this request is not 
medically necessary because the enrollee does not have a compendia-supported diagnosis/condition for use of 
this drug. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Leqvio. Our reviewer says that Leqvio 
is not medically reasonable and necessary. Our physician reviewer found the record indicates that the enrollee 
has a diagnosis of non-familial hypercholesterolemia with evidence of atherosclerotic cardiovascular disease. 
The Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's 
condition. Our reviewer found that the Medicare approved drug compendia do not contain a supportive citation 
for the use of the requested drug in the enrollee's clinical situation. The elements of the coverage criteria are not 
satisfied. Our physician reviewer also found that 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 Leqvio have not been met. 
  
 
 Therefore, we decided that the Plan does not have to pre-approve Leqvio.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) of the lower extremity 
without contrast material (73700). 
 
You asked the Plan to pre-approve a CT scan. You say that the enrollee has tried and failed all conservative 
treatments and requires imaging to prepare for other options. The Plan denied your request. The Plan says the 
CT scan is not medically necessary, because this scan is requested solely to plan for robot assisted surgery. 
 
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 a CT scan. Our reviewer says that the 
requested imaging service is not medically necessary and reasonable in this case. Our physician reviewer found 
that this CT scan is requested for an enrollee with left knee osteoarthritis. She presented with bilateral knee 
pain and buckling in both her knees. The left knee exam reveals slight swelling, and a Bakers cyst is 
appreciated in the posterior aspect of her knee. However, the documentation does not clearly verify for which 
knee this request is for. The appeal indicates the CT is for the left knee and the surgery request indicates the 
surgery is for the right knee. Regardless, there is limited published, large-scale, long-term peer-reviewed 
literature that shows this request to be an effective and/or safe treatment for the noted pathology. Long term 
large volume studies have not demonstrated improved long-term function or pain relief with the CT scan in this 
setting. There is no compelling rationale presented or extenuating circumstances noted to support the medical 
necessity of this request as an exception. Therefore, the requested CT scan of the lower extremity without contrast (CPT 73700), in this case, is not medically reasonable or 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 a CT scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve computed tomography (CT) of the lower extremity without contrast material (73700).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the portion of the genetic testing provided on May 12, 2021, 
billed with code 81404. 
 
You asked the Plan to pay for this portion of the genetic testing. You say that this testing as not medically 
necessary. The Plan denied your request. The Plan says the ordering provider listed on the claim states this 
testing was not ordered. Since this was not ordered by a physician, only 5 of the 7 line items will be paid. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 We looked at the file and Medicare rules. The documentation does not support that this testing was to be used 
in the management of the enrollee's condition. Based on this information, we decided that Medicare rules for 
coverage of this portion of the genetic testing have not been met. Therefore, we decided that the Plan does not 
have to pay for the portion of the genetic testing provided on May 12, 2021, billed with code 81404.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal ultrasound provided on January 14, 2022. 
 
You asked the Plan to pay for the services provided. You say that the procedure was rendered in the 
appropriate place of service. The Plan denied your request. The Plan says the claim was billed with an 
inappropriate place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
 
 
 We find that the ultrasound was provided while the enrollee was receiving inpatient care. The facility must 
furnish all necessary covered services to the beneficiary either directly or under arrangements made with 
outside providers. This service was provided via arrangement of the facility. Payment for this service would 
have been included under the facility claim. Payment to you for this service is the responsibility of the facility.  
Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pay for the abdominal ultrasound provided on January 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle continuous glucose monitor (CGM) device 
and related supplies. 
 
You asked the Plan to pre-approve a Freestyle CGM and supplies. You say that the items/services at issue are a 
medical necessity for you. The Plan denied your request. The Plan says rules for coverage for CGMs and 
related supplies 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 available documentation does not indicate that you use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
Freestyle CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Freestyle continuous glucose monitor (CGM) device and related supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services provided on January 13, 2022. 
 
You asked the Plan to pay for the services provided. You say that there were no medical necessity or coding 
issues found. The Plan denied your request. The Plan says medical necessity cannot be determined. 
 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 01992 is anesthesia for diagnostic or therapeutic nerve 
blocks and injections (when block or injection is performed by a different physician or other qualified health 
care professional); prone position. 
 
We find that CPT code 01992 is not supported in the medical record. The file shows anesthesia services were 
provided during a sacroiliac joint injection. There are insufficient records to show that the enrollee had a 
medical condition that required anesthesia services during the injection. Based on this information, we decided 
that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the 
Plan does not have to pay for the anesthesia services provided on January 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cytogenetics services coded 88291 and 88368 provided 
on October 25, 2021. 
 
You asked the Plan to pay for the cytogenetics services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services billed are not separately payable. 
 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, we have confirmed that codes 
88291 and 88368 are a column II code to column I codes 81407, 81347, and 81263. This claim has not been 
billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria 
have not been met. Therefore, we decided that the Plan does not have to pay for the cytogenetics services coded 
88291 and 88368 provided on October 25, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the breast ultrasound provided on December 7, 2021. 
 
You asked the Plan to pay for the breast ultrasound. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are a duplicate. 
 
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 76641 is ultrasound, breast, unilateral, real time with 
image documentation, including axilla when performed; complete. 
 
We find that CPT code 76641 is not supported in the medical record. Specifically, the documentation shows 
that this charge is a duplicate as the Plan has already processed and paid this code for this date of service. 
Based on this information, we decided that Medicare rules for coverage of the breast ultrasound have not been 
met. Therefore, we decided that the Plan does not have to pay for the breast ultrasound provided on December 
7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care services coded 99233 provided 
on August 31, 2021. 
 You asked the Plan to pay for the subsequent hospital care services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services billed are not separately 
payable. 
 
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, we have confirmed that code 99233 
is a column II code to column I code 99222. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the subsequent hospital care services coded 99233 provided on 
August 31, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve duloxetine capsules. 
 
You asked the Plan to pre-approve self-administered drug. You say that it is in the enrollee's best interest to use 
this drug. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, 
because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare 
Part D prescription drug benefits. 
 
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 duloxetine capsules.  
 
Benefits for self-administered drug 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on December 22, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the laboratory services provided on December 22, 2021.