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

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device 
(HFCWOD). 
 
You asked the Plan to pre-approve a HFCWOD. You say that this is medically necessary. The Plan denied your 
request. The Plan says the computed tomography (CT) scan revealed pulmonary nodules and emphysema 
without evidence of bronchiectasis. 
 
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.   
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 HFCWOD. Our reviewer says that a 
high-frequency chest wall oscillation device is not medically necessary. Our physician reviewer found that this 
patient has severe COPD.  There is no diagnosis of cystic fibrosis, bronchiectasis, or neuromuscular 
disease.  Medicare does not cover this device for COPD because there is inadequate evidence of safety and 
effectiveness for this diagnosis.  
 
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 HFCWOD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a high frequency chest wall oscillation device (HFCWOD).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation with an out-of-network specialist. 
 
You asked the Plan to pre-approve an out-of-network specialist consult. You say that the enrollee has a 
complicated diagnosis that requires high-risk surgery. You say that the enrollee has had consults with a 
colorectal surgeon and urogynecologist who have declined to do the surgery. You also say that both providers 
recommended a referral to a surgeon who specializes in complex pelvic floor repairs. The Plan denied your 
request. The Plan says the requested consultation can be provided by a network provider. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet the enrollees needs. The enrollees contract with the Plan says that, with few 
exceptions, enrollees must use contract providers for care.  
 
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 out-of-network specialist consult. 
Our reviewer says that the requested out-of-network specialist consult is not medically necessary. Our 
physician reviewer found there is nothing unique about the enrollee's condition that that would make it 
medically necessary for her to see the requested out-of-network provider. The plan has shown that they have an 
in-network provider who meets the Standards of Care required for treatment of the enrollee's condition. 
Therefore, the reviewer found that the requested out-of-network specialist consult is not 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 an out-of-network specialist consult have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a consultation with an out-of-network specialist.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vacuum socket (L5781) and advanced foot with ankle 
feature (L5981 and L5986). 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee is very active. The Plan 
denied your request. The Plan says a prosthesis that meets, but does not exceed, the enrollee's needs can be 
provided. 
 
The Plan follows Medicare rules. Medicare rules say that lower limb protheses are only covered under certain 
medical indications.  
 
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 requested services. Our physician 
reviewer found that an advanced foot with ankle feature (L5981 and L5986) exceeds the enrollees medical 
needs and is not medically necessary. The medical provider documentation is conflicting on the enrollees need 
for a level 3 (K3) foot. The documentation notes the enrollee was a limited ambulator when approved for a 
power wheelchair in 2021. The documentation does not support that the enrollee is a K3 ambulator.   
 
A vacuum pump (L5781) exceeds the enrollees medical needs and is not proven superior to a standard socket. 
The literature reviewed indicates that further research is needed with clinical trials that recruit larger sample 
sizes and report long-term outcome data for the requested vacuum suspension system. Therefore, a vacuum 
pump is not 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a vacuum socket (L5781) and advanced foot with ankle feature (L5981 and 
L5986).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for  a prefabricated knee orthosis (L1851) for the enrollee.

You asked the Plan to provide coverage for the requested orthosis. You say that at the time of the appeal, the requested orthosis was medically necessary. The Plan denied your request. The Plan says the Medicare coverage criteria were not met. Maximus overturned the Plans denial for insufficient medical records in the case file. The Plan requested a reopen and submitted the records provided by your office. The Plan states the records provided do not show the documentation required to approve the orthosis requested are present.

The Plan is correct in this case. 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 corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of the requested orthosis have been met. Therefore, we decided that the Plan does not have to provide coverage for  a prefabricated knee orthosis (L1851) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that you disagree with the denial and requesting 
reconsideration. The Plan denied your request. The Plan says the records do not show that the enrollee has had 
atrial blood gases with abnormally low oxygen or elevated carbon dioxide, or that she has had sleep oximetry 
testing. Additionally, the order for the ventilator is for exclusive use in a BiPap setting. 
 
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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has a diagnosis of 
chronic respiratory failure consequent to chronic obstructive pulmonary disease. Provided records document 
that the home ventilator is being requested for use in average volume assured pressure support (AVAPS) mode 
with auto-EPAP (AE) which could be provided by a BiPAP device with AVAPS and a back-up rate. Provided 
records do not document trial and failure of a BiPAP device with AVAPS and a back-up rate. As stated in the 
Local Coverage Determination (L33800): "Claims for ventilators used to provide CPAP or bi-level CPAP 
therapy for conditions described in this RAD policy will be denied as not reasonable and 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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on August 25, 2022.

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 that this is an administrative determination for billing and is not based on clinical criteria for medical necessity. The claim was billed with a place of service (POS) 81, Independent Laboratory, independent of an institution or a physician's office. An independent laboratory taking a sample in its laboratory shows "81" as place of service. However, the records show the specimen was collected during an outpatient encounter.

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 POS code. Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on August 25, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a computed tomography (CT) of brain without contrast 
material (70450), provided on September 21, 2022. 
 
You asked the Plan to pay for the CT. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says diagnosis code F05 has a code first note and is not 
acceptable as a primary diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that for such conditions, the ICD-10-CM has a coding 
convention that requires the underlying condition be sequenced first, if applicable, followed by the manifestation. 
 
Specifically, this claim was billed with primary diagnosis code F05. Diagnosis code F05 has a code first note 
indicating that it is not an appropriate primary diagnosis. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the CT have not been met. Therefore, we decided that the Plan does not have to pay for a computed 
tomography (CT) of brain without contrast material (70450), provided on September 21, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services rendered from January 11, 2022, 
to January 22, 2022. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says the Payment Integrity post-service post-pay clinical validation audit shows that the provider has reported inpatient hospital services with the incorrect 
DRG. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 515. 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 inpatient hospital services at the DRG originally billed. Our reviewer says 
that the services at issue in this case were not supported by the medical records. Our physician reviewer found 
that the actual nutrition status is not known in this case. The coded diagnosis of E43 is not supported by the 
documentation. In addition, there was no specific intervention directed towards severe malnutrition. The 
intervention was non-specific. There were no complications associated with severe malnutrition.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services rendered from January 11, 2022, to January 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 Mis continuous glucose monitor (CGM) 
sensor. 
 
You asked the Plan to pre-approve a Dexcom G6 CGM. You say that the enrollee needs this CGM to track his 
glucose readings. The device will alert him when his glucose is too low. The Plan denied your request. The 
Plan says the enrollee does not meet criteria for approval of the requested 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 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 Dexcom 
G6 CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 
Mis continuous glucose monitor (CGM) sensor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the vision services (99214, 99058) 
provided to you on January 3, 2023. 
 
You asked the Plan to waive the copayment. You say that this provider is in-network. 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 $65 
copayment for out-of-network vision services. Medicare rules also say that providers must report services 
correctly. Providers must report services with the appropriate procedure code. 
 
Review of the file shows that you were provided out-of-network vision services (99214) on January 3, 2023. 
You have been asked to pay a $65 copayment for the services. The services fall within the vision care 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. 
 
We also find that procedure code 99058 has a status indicator of B on the Physician Fee Schedule. This means 
that procedure code 99058 is not separately payable. 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 waive the 
copayment for the vision services (99214, 99058) provided to you on January 3, 2023.
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 for the enrollee.

You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that based on Medicare guidelines and the information we have about the enrollee's condition he does not meet all the requirements.

Our Medical director looked at the case file and the reopen request. At issue is coverage for IRF care. Our Medical Director states that the documentation does not support that the complexity of the enrollee's nursing, medical and rehabilitation needs required an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care.

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 for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an acute inpatient psychiatric hospitalization provided on 
October 11, 2022, to October 17, 2022. 
 
You asked the Plan to pay for an acute inpatient psychiatric hospitalization. You say that this admission was 
medically necessary. The Plan denied your request. The Plan says these services were not medically necessary. 
 The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 an acute inpatient psychiatric 
hospitalization. Our reviewer says that this inpatient admission was not medically necessary. Our physician 
reviewer found acute inpatient psychiatric hospitalization and could have been treated in a lesser restrictive 
setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an acute inpatient psychiatric hospitalization have not been met. Therefore, we 
decided that the Plan does not have to pay for an acute inpatient psychiatric hospitalization provided on 
October 11, 2022, to October 17, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the Regadenoson injection (J2785), Technetium TC-99M tetrofosmin, 
diagnostic, per study dose, up to 40 millicuries (A9502), and cardiac stress imaging test (G8962). 
 
You asked the Plan to pay for the Regadenoson injection, Technetium TC-99M tetrofosmin, and cardiac stress 
imaging test. You say that the service is medically necessary. The Plan denied your request. The Plan says that 
the service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 pay for the Regadenoson injection, Technetium TC-
99M tetrofosmin, and cardiac stress imaging test. Our reviewer says that the requested services are considered 
medically reasonable and necessary in this case. Our physician reviewer found the enrollee underwent an 
evaluation with chest pain and shortness of breath. 
 
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 Regadenoson injection, Technetium TC-99M tetrofosmin, and cardiac stress 
imaging test have been met. Therefore, we decided that the Plan has to pay for the Regadenoson injection 
(J2785), Technetium TC-99M tetrofosmin, diagnostic, per study dose, up to 40 millicuries (A9502), and 
cardiac stress imaging test (G8962).  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental services (D6010, D6051, D6057, D6065). 
 
You asked the Plan to pre-approve the dental services (D6010, D6051, D6057, D6065). You say that you 
would like to request reconsideration of the denied authorization. The Plan denied your request. The Plan says 
the services requested are not covered benefits. 
 
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 pre-approve the 
dental services (D6010, D6051, D6057, D6065).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided on October 2, 2021, 
to October 5, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. The Plan denied your 
request. The Plan says the billed DRG is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with diagnosis code J18.9. 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 inpatient hospital services at the DRG originally billed. Our 
reviewer says that the use of diagnosis code J18.9 is not supported by the records provided. Our physician 
reviewer found that the enrollee was a then, 59-year-old male who presented to the facility on October 2, 2021, 
with shortness of breath. The past medical history included chronic low back pain, chronic obstructive 
pulmonary disease (COPD), hypertension, and enlarged prostate. The enrollee was admitted for treatment of 
COPD exacerbation. In this case, the clinical evidence did not support the diagnosis of community acquired 
pneumonia. The documentation did not support J18.9.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for the inpatient hospital services provided on October 2, 2021, to October 5, 2021, at the Diagnosis Related 
Group (DRG) originally billed.