Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits (99204, 99205, 99213x6, 99214x6, 
99215x6) with a cardiologist to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve office visits with a cardiologist. You say that the enrollee has had tests read 
by this doctor and this provider is familiar with the enrollees condition. The Plan denied your request. The 
Plan says the enrollee must use network providers to get medical care and services. There are three providers 
who have been confirmed to be in the enrollee's network. The doctors can provide services based on the 
enrollee's diagnoses specifically services relate to health issues, and they are all within 20 miles or less from the 
enrollee's home. 
 
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 
office visits (99204, 99205, 99213x6, 99214x6, 99215x6) with a cardiologist to be provided by an out-of-
network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve CGM. You say that this device is to help manage the enrollee's glucose and 
it has been beneficial for health. The Plan denied your request. The Plan says the enrollee does not meet criteria 
for a CGM. 
 
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. Based on this information, we decided that Medicare rules for coverage of 
CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 2 
continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lower extremity prosthesis included in a flex-walk 
system (L5981). 
 
You asked the Plan to pre-approve a flex-walk system. 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 follows Medicare rules. Medicare rules say that a microprocessor controlled ankle foot system 
(L5973), energy storing foot (L5976), dynamic response foot with multi-axial ankle (L5979), flex foot system 
(L5980), flex-walk system or equal (L5981), or shank foot system with vertical loading pylon (L5987) is 
covered for beneficiaries whose functional level is 3 or above. 
 
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 flex-walk system. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found the documentation doesn't support 
that the enrollee requires the requested upgraded foot and components for a lower extremity prosthesis. The 
documentation indicates he is not a K3 level ambulator. 
 
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 flex-walk system have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a lower extremity prosthesis included in a flex-walk system (L5981).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation feature.
 
You asked the Plan to pre-approve the services. You say that this should be paid for. The Plan denied your 
request. The Plan says this is not a covered benefit. 
 
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 power seat elevation feature.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the group 3 power wheelchair with a single power option.

You asked the Plan to pre-approve the group 3 power wheelchair. You say that you would like reconsideration because the group 2 power wheelchair is not suitable for your needs. The Plan denied your request. The Plan says the requested power wheelchair is not medically necessary.

The Plan follows Medicare rules. Medicare rules say that for a group 3 power wheelchair with a single power option to be covered, the beneficiary must require a drive control interface other than a hand or chin-operated standard proportional joystick or must meet coverage criteria for a power tilt or power recline seating system.

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 group 3 power wheelchair. Our reviewer says that you do not meet Medicare criteria for coverage of the requested power wheelchair. The request for a group 3 power wheelchair with a single power option exceeds your medical needs. Our physician reviewer found you do not meet coverage criteria for a power tilt or power seating system. The documentation does not reveal that you use a ventilator attached the the wheelchair, are at high risk of pressure ulcer or use intermittent catheterization. The physician documentation does not indicate objective evidence of spasticity that needs a power seating system for management. You do not require a drive control interface other than a hand or chin-operated standard proportional joystick. The seat elevator does not serve a primary medical need.

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 group 3 power wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve the group 3 power wheelchair with a single power option.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for disposable contact lenses (S0500) provided on June 27, 
2022. 
 
You asked the Plan to pay for disposable contact lenses (S0500). You say that you are appealing because the 
claim was denied. The Plan denied your request. The Plan says the $84 will be upheld, however, since that was 
the cost of the contacts that could not be covered due to the member having used their $200 allowance. 
 
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 allowance for supplemental eyewear every year. 
 
We looked at the file and the Plan's rules. The Plan rules say there is a $200 allowance for supplemental 
eyewear every year. The Plan rules also say members are responsible for all costs over and above the allowance 
amount. The record shows that this benefit was exhausted on June 27, 2022. Based on this information, we 
decided that the Plan's rules for coverage of disposable contact lenses (S0500) have not been met. Therefore, 
we decided that the Plan does not have to pay for disposable contact lenses (S0500) provided on June 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care services coded 99232 provided 
on February 21, 2022. 
 
You asked the Plan to pay for the subsequent hospital care services. You say that you disagree with the Plan's 
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. 
 
We find that CPT code 99232 is not supported in the medical record. Specifically, this service was provided on 
the same date of service as surgery procedure 93458 (Catheter placement in coronary artery(s) for coronary 
angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and 
interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculography, 
when performed). Code 99232 was not billed with an appropriate modifier, so code 99232 is included in the 
global surgery period of code 93458. Based on this information, we decided that Medicare rules for coverage of 
the subsequent hospital care services have not been met. Therefore, we decided that the Plan does not have to 
pay for the subsequent hospital care services coded 99232 provided on February 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for the routine eyewear (V2020, V2781, 
V2784, V2799) provided on August 26, 2022. 
 
You asked the Plan to provide additional payment for the routine eyewear. You say that you called prior to 
your exam to verify that the provider was in-network. The Plan denied your request. The Plan says this claim 
has processed correctly. 
 
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 up to $225 every year. 
 
We looked at the file and the Plan's rules. The Plan provided documentation showing that your claim was 
reprocessed, and the Plan reimbursed the full $225 routine eyewear allowance. You have been asked to pay the 
remaining cost above this amount. 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 provide additional payment for the routine 
eyewear (V2020, V2781, V2784, V2799) provided on August 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on August 15, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the dental service (D2950) is not a covered service. 
 
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. 
 
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 dental 
services on August 15, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71045 billed for date of service October 13, 
2022. 
 
You asked the Plan to pay for procedure code 71045. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 71045 is bundled into payment for code 71046. 
 
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 71045 
is a column II code to column I code 71046. 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 procedure code 71045 billed for date of service October 13, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve electronic connection between wheelchair controller and 
two or more power seating system motors, including all related electronics, indicator feature, mechanical 
function selection switch, and fixed mounting hardware (CPT code E2311), expandable controller, including 
all related electronics and mounting hardware, upgrade provided at initial issue (E2377) and harness for 
upgrade to expandable controller (E2313). 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says the DME is not necessary. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the DME have not been met. Upgraded electronics (electronic 
connector) cannot be covered per Medicare rules. They are necessary when there is a medical need to control 
power options though the joystick. The notes do not show a medical need to control the power options through 
the joystick. The power options can be controlled using their own switches. These switches can be made any 
size without asking for a separate request. They can be made from any material without asking for a separate 
request. All of this can be done without the need to use the joystick to control the power features. Therefore, we 
decided that the Plan does not have to pre-approve electronic connection between wheelchair controller and 
two or more power seating system motors, including all related electronics, indicator feature, mechanical 
function selection switch, and fixed mounting hardware (CPT code E2311), expandable controller, including 
all related electronics and mounting hardware, upgrade provided at initial issue (E2377) and harness for 
upgrade to expandable controller (E2313).
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Uplizna.

You asked the Plan to pre-approve Uplizna. 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.

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 Uplizna. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has not tried and failed the required drug. There is no documentation provided indicating that the plan's required drug would likely be less effective and/or likely have adverse effects for the 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 Uplizna have not been met. Therefore, we decided that the Plan does not have to pre-approve Uplizna.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 3 lower limb prosthetic socket inserts (code L5673, 3 
units). 
 
You asked the Plan to pre-approve lower limb prosthetic socket inserts. You say that the enrollee is in need of a 
new socket. The Plan denied your request. The Plan says no more than 2 of the same socket inserts are allowed, 
so a request for 3 socket inserts exceeds the enrollee's needs. 
 
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 lower limb prosthetic socket inserts. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found only up to 2 replacement sockets are medically necessary; therefore, 
this request exceeds needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lower limb prosthetic socket inserts have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 3 lower limb prosthetic socket inserts (code L5673, 3 units).
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for neuromonitoring services (95937, G0453) provided on May 6, 2022. 
 
You asked the Plan to pay for the neuromonitoring services. You say that this service was medically necessary. 
The Plan denied your request. The Plan says that they were unable to make a determination within the allotted 
timeframe. 
 
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. The plan did not provide any documentation or rationale to support the denial. 
Therefore, we decided that the Plan has to pay for neuromonitoring services (95937, G0453) provided on May 
6, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee extension for a prosthetic. 
 
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 medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a knee extension 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 pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found there is no evidence in the submitted 
records that the enrollee requires assist with extension beyond what a standard brace can provide. The knee has 
impaired flexion, not extension. The services are not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a knee extension for a prosthetic.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (12001) billed to the enrollee for date of service October 1, 2021.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated Maximus did not apply the correct billing criteria. The Plan notes that the non-participating provider is appealing the denial of procedure code 12001 (simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities) provided on date of service October 1, 2021. Surgery procedure code 28490 performed on September 5, 2021, has a global value of 090 on the CMS National Physician Fee Schedule (NPFS) Relative Value (RVU) file. This is a major procedure that has a global surgery period of 90 days. Procedure code 12001 billed on date of service October 1, 2021, is included within the global surgery package of procedure code 28490 billed on date of service September 5, 2021.
The Medicare Claims Processing Manual Chapter 12 Section 40.2 paragraph 7 states Modifiers were established to simplify billing for visits and other procedures which are furnished during the post operative period of a surgical procedure, but which are not included in the payment for the surgical procedure. Modifier "-79": Reports an unrelated procedure by the same physician during a postoperative period. The physician may need to indicate that the performance of a procedure or service during a postoperative period was unrelated to the original procedure. The Medicare Claims Processing Manual Chapter 12 Section 40.4 paragraph "A" states separate payment is allowed for visits and procedures billed with modifier "-78," "-79," "-24," "-25," "-57," or "-58." Modifier "-24" must be accompanied by sufficient documentation that the visit is unrelated to the surgery. Medicare billing do not allow separate payment for an additional procedure(s) with a global surgery fee period if furnished during the postoperative period of a prior procedure and if billed without modifier "-58," "-78," or "-79." These services should be denied. Both services were performed by different physicians from the same group practice with the same specialty. The Medicare Global Surgery Booklet says this would be "one physician." That aspect also justifies the uphold on the case due to missing modifier 79 since the modifier description technically is for the "same physician."
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 CPT code. In this case, this claim could not be paid as billed due to the omission of a required modifier. Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for physician services (12001) billed to the enrollee for date of service October 1, 2021.