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

 
We decided that the Plan does not have to pay for the oxygen concentrator (E1390) purchased on September 
29, 2022. 
 
You asked the Plan to pay for the oxygen concentrator. You say that the item is medically necessary and should 
be covered. The Plan denied your request. The Plan says purchased oxygen equipment is statutorily non-
covered. 
 
The Plan must follow Medicare rules. Medicare rules say that reimbursement for oxygen equipment is limited 
to 36 monthly rental payments. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the oxygen concentrator have not been met. Specifically, you purchased this equipment and 
Medicare only covers the rental of this equipment. Therefore, we decided that the Plan does not have to pay for 
the oxygen concentrator (E1390) purchased on September 29, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on April 11, 2022.
You asked the Plan to pay for this service. You say that this claim should be paid 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. The Plan requested a reopen and provided additional information.
The Plan says that this claim denied because the claim was billed with an inappropriate diagnosis code. The
diagnosis code billed was K64.9 (Unspecified hemorrhoids) with procedure code 88305. The American
Medical Association description for procedure code 88305 explains this service involves a level of surgical
pathology and gross microscopic examination that does not include the indication of Hemorrhoids. The medical
records show this service as Ileocecal valve polyp biopsy. The provider should have billed procedure code
46945 which is a medical procedural code under the range for Excision Procedures on the Anus.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. In this case, this claim was billed with an inappropriate procedure code. Medicare
rules for coverage of these service have not been met. Therefore, we decided that the Plan does not have to pay
for lab services provided to the enrollee on April 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99214 billed for date of service November 4, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the code is separately payable. The Plan denied 
your request. The Plan says the payment for surgery includes same day visits. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
 The file shows that code 99214, billed with the -25 modifier, was billed with minor procedure code 20552. The 
records do not show that a significant, separately identifiable evaluation and management service was 
provided. Visits by the same physician on the same day as a minor surgery are included in the payment for the 
procedure. Based on this information, we decided that Medicare rules for coverage of the billed services have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99214 billed for 
date of service November 4, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the patient meets full IRF criteria and this care is 
needed for her to regain maximum function. The Plan denied your request. The Plan says IRF care is not 
medically necessary because the patient's needs can be met at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for septic shock, anemia, Clostridium difficile colitis, cellulitis and venous stasis ulcerations and 
metabolic encephalopathy. Their medical problems are stable and there are no complex nursing or 
rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record 
supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a 
reasonable expectation that this patient will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer (J1439). 
 
You asked the Plan to pre-approve Injectafer. You say that Injectafer is medically necessary. The Plan denied 
your request. The Plan says a trial of Infed or Venofer is required before alternatives can be considered. 
 
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 Injectafer. Our reviewer says that 
Injectafer is not medically necessary. Our physician reviewer found the record shows no trial of the plan 
preferred drugs, or any reason they would be unsafe or ineffective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer (J1439).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle kit sensor. 
 
You asked the Plan to pre-approve a FreeStyle kit sensor. You say that the enrollee would benefit with a CGM. 
The Plan denied your request. The Plan says the enrollee is not on insulin. 
 
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 FreeStyle 
kit sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a FreeStyle kit 
sensor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton treatment delivery, intermediate. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this request is not the standard of care for prostate cancer. 
 
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 services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is insufficient prospective, long-term clinical data available to determine whether or not proton 
beam radiation therapy for prostate cancer is superior, inferior, or equivalent to external beam radiation 
therapy, intensity modulated radiation therapy (IMRT), or brachytherapy with regards to safety and efficacy. 
Recent data shows no significant differences in late (years one, two, and three) patient-reported toxicity 
outcomes between proton beam therapy and IMRT. 
 
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 proton treatment delivery, intermediate.
Appeal type: Home Health
Decision: Unfavorable

We decided the Plan does not have to pay for home health care provided from February 1, 2022, to February
15, 2022.
You asked the Plan to pay for these services. 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 provided additional information. The Plan noted this claim was billed with an
incorrect Type of Bill (TOB) code. The Plan states this service was inappropriately billed TOB 323 or Home
Health Agency/Inpatient/Interim-Continuing Claims. The claim should have been billed with TOB 322, 329, or
327. The Plan provided a copy of the incorrect claim.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. In this case, this claim could not be paid due to an error with the reported TOB code.
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pay for home health care provided to the enrollee from February 1, 2022, to February 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oxygen equipment purchased on October 25, 2022. 
 
You asked the Plan to pay for the oxygen equipment. You say that the item was medically necessary and 
should be covered. The Plan denied your request. The Plan says this item was purchased. 
 
The Plan must follow Medicare rules. Medicare rules say that only rented oxygen equipment is eligible for 
coverage. Purchased oxygen equipment is statutorily non-covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the oxygen equipment have not been met. Specifically, you purchased the item and Medicare only 
covers oxygen equipment when it is rented. Therefore, we decided that the Plan does not have to pay for the 
oxygen equipment purchased on October 25, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoperative EEG provided on May 17, 2022. 
 
You asked the Plan to pay for the intraoperative EEG. The Plan denied your request. The Plan says the 
requested intraoperative EEG was not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the intraoperative EEG. Our reviewer says 
that the requested EEG is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the enrollee was a then 72-year-old who underwent a left total knee arthroplasty. 
Intraoperative neurophysiologic monitoring included EEG. The technical report notes "Depth of anesthesia only". The documentation available does not support that the intraoperative EEG at issue was medically 
reasonable and necessary for the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the intraoperative EEG have not been met. Therefore, we decided that the Plan 
does not have to pay for an intraoperative EEG provided on May 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the face down chair (E1399) provided from August 29, 2022, 
to September 23, 2022. 
 
You asked the Plan to pay for the face down chair. You say that you would like to be reimbursed the $433 you 
paid out of pocket for this medically necessary equipment. The Plan denied your request. The Plan says the 
face down position could be achieved by pillows. The Plan also says this equipment is 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 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 pay for the face down chair (E1399) provided from August 29, 2022, to 
September 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an over bed table (E0274). 
 
You asked the Plan to pre-approve an over bed table. You say that it is difficult for you to get in and out of bed. 
The Plan denied your request. The Plan says an over bed table 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 an over bed table (E0274).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on August 24, 2022. 
 
You asked the Plan to pay for the lab services. You say that the documentation supports medical necessity. The 
Plan denied your request. The Plan says there is a more appropriate code for this service. 
 
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 87506 is infectious agent detection by nucleic acid (DNA 
or RNA); gastrointestinal pathogen multiple types or subtypes, 6-11 targets. We find that CPT code 87506 is 
not supported in the medical record. Specifically, there is a more appropriate code to describe the number of 
targets tested in this case. Based on this information, we decided that Medicare rules for coverage of the lab 
services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services 
provided on August 24, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that not receiving skilled nursing care would impact 
your health. The Plan denied your request. The Plan says the Medicare criteria for SNF admission was not met 
and the enrollee can receive the care that they need at home with home health care services. 
 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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. The records support that 
services in the home with home health care or in a long-term care facility on a part time basis are appropriate in 
this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an automatic external defibrillator (AED) garment (K0606)
billed to the enrollee for date of service October 10, 2021.
You asked the Plan to pay this claim. You say that this automatic external defibrillator (AED) garment (K0606)
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. The Plan requested a
reopen and provided additional information. The Plan demonstrated that devices coded as K0606 must include
the KF modifier. Claim lines billed without a KF modifier will be rejected as missing information based on the
Medicare guidelines. The claim shows code K0606 not billed with the required KF modifier. Therefore, this
claim should not be paid as 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 code and when required the
appropriate modifier. In this case, the claim was not billed with the appropriate modifier. Therefore, we
decided that the Plan does not have to pay for an automatic external defibrillator (AED) garment (K0606)
billed to the enrollee for date of service October 10, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Pomalyst capsule 2mg. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says this self-administered drug does not fall under Part B 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 Pomalyst capsule 2mg.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy visits. 
 
You asked the Plan to pre-approve the therapy services. You say that you are benefitting from physical therapy. 
The therapy is not just for your knees, it is also for your back, neck, head and tendons. Physical therapy is the 
only thing you can do to reduce pain. You say you fall much less then before physical therapy. The Plan denied 
your request. The Plan says the records sent to us do not support the request for treatment, more skilled 
treatment is not needed at this time. 
 
 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the enrollee has extensive history of physical therapy and is able to 
benefit from repetitive exercise. There is no evidence unique input from a skilled therapist remains 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 the therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve physical therapy visits.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox injections (J0585). 
 
You asked the Plan to pre-approve Botox injections. The Plan denied your request. The Plan says the enrollee 
does not have a documented medical condition for which Botox is covered by Medicare. 
 
The Plan follows Medicare rules. Medicare rules say that Botulinum toxin is indicated for disorders associated 
with spastic conditions and dystonia. 
 
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 Botox injections. Our reviewer says 
that there is no documentation that the Botox at issue in this case meets all Medicare criteria for medically 
reasonable and necessary for the enrollee. Our physician reviewer found there is no documentation that the 
Botox at issue in this case meets all Medicare criteria for safe and effective for the enrollee. Our reviewer also 
found that hereditary and idiopathic neuropathy, unspecified and radiculopathy, lumbar region with intense 
cramping in the right calf are not medically accepted indications for use of Botox as defined by the Local 
Coverage Article and the Medicare-approved major drug compendia. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox injections have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Botox injections (J0585).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve irrigation trays (A4320). 
 
You asked the Plan to pre-approve the irrigation trays. You say that these items are medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that when syringes, trays, sterile saline, or water are 
used for routine irrigation, they will be denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. The trays are for routine irrigation. Based on this information, we 
decided that Medicare rules for coverage of the irrigation trays have not been met. Therefore, we decided that 
the Plan does not have to pre-approve irrigation trays (A4320).