Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MILD procedure at L3-L5 for the enrollee. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says the requirement is you are enrolled in an approved clinical study for lumbar spinal 
stenosis (narrowing of the spine in your lower back). 
 
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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found detailed documentation is not evident regarding trial and failure of recent, reasonable, and 
comprehensive less invasive conservative care measures. There are limited large-scale, long-term references 
showing the safety and efficacy of the requested surgery 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 to guidelines. Therefore, the requested MILD procedure at L3-L5, 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 the procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the MILD procedure at L3-L5 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lightweight wheelchair (K0003). 
 
You asked the Plan to pre-approve a lightweight wheelchair. You say that the enrollee has pain in her leg and a 
walker or cane cannot hold her up. Trying to move with a walker causes her more pain. She has difficulty 
walking and the doctor wont give her medication and she is allergic to ibuprofen. The Plan denied your 
request. The Plan says the records do not support that the enrollee does not meet the criteria. 
 The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 lightweight wheelchair. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation states that the enrollee has a mobility deficit, but the 
documentation does not support that the mobility limitation significantly impairs her ability to participate in 
one or more mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, 
grooming, and bathing in customary locations in the home. The documentation does not support that the 
enrollee's mobility limitation cannot be sufficiently resolved by the use of an appropriately regular manual 
wheelchair. The documentation does not support that the use of a K003 manual wheelchair will significantly 
improve the enrollee's ability to participate in MRADLs and the enrollee will use it on a regular basis in the 
home. 
 
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 lightweight wheelchair have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a lightweight wheelchair (K0003).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total abdominal hysterectomy (58150) with inpatient 
admission. 
 
You asked the Plan to pre-approve a total abdominal hysterectomy. You say that that the requested service is a 
medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for the 
requested service have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a total abdominal hysterectomy. Our 
reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the record indicates that the enrollee has endometriosis and menorrhagia. The 
record does not provide documentation of anemia and a failure of medical therapies. The record provided is 
insufficient to establish the medical necessity and reasonableness, as defined by Medicare rules, of the 
requested service. 
 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 total abdominal hysterectomy have not been met. Because the base procedure 
is not covered, the related inpatient admission is also not approved. Therefore, we decided that the Plan does 
not have to pre-approve a total abdominal hysterectomy (58150) with inpatient admission.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be more stable and improving and should only require short-
term additional acute care services that can safely be completed at the current facility until more appropriate for 
a lower level of care. There are no services at the LTACH that the enrollee requires that are not already 
available and covered at the current facility. Transfer to a lower level of care may be considered when 
treatment has completed. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interspinous process spacer. 
 
You asked the Plan to pre-approve the interspinous process spacer. The Plan denied your request. The Plan 
says this is 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 pre-approve the interspinous process spacer. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found that interspinous process stabilization devices remain experimental in cases of 
spinal fusion. More research is needed for this device. 
 
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 interspinous process spacer have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an interspinous process spacer.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cardiac catheterization. 
 
You asked the Plan to pre-approve cardiac catheterization. The Plan denied your request. The Plan says this is 
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 pre-approve cardiac catheterization. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee is asymptomatic. The guidelines do not support a need for cardiac 
catheterization in this setting. As a result, at this time cardiac catheterization would not be considered 
medically reasonable and necessary in this enrollees clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of cardiac catheterization have not been met. Therefore, we decided that the Plan 
does not have to pre-approve cardiac catheterization.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a hand x-ray and an emergency room (ER) 
visit provided from November 23, 2021, to November 24, 2021. 
 
You asked the Plan to waive the copayments for an x-ray and an ER visit. You say that you were not in the 
hospital on November 23, 2021, but you were there on November 24, 2021. The Plan denied your request. The 
Plan says you have been charged the correct cost sharing amount. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for an x-ray. The Plan contract also says that enrollees must pay a $90 copayment for an emergency 
room visit. The Plan contract also says that doctors, hospitals, and other health care providers will ask you to 
pay cost shares (copayments and/or coinsurance) for each covered service you have during a visit. 
 
The medical record shows you received services at the hospital from November 23, 2021, to November 24, 
2021. According to the EOC, cost sharing applies to each covered service you have during a visit. You have 
been asked to pay a $40 copayment for an x-ray. An x-ray falls within the Outpatient Diagnostic Tests and 
Therapeutic Services and Supplies benefit category. You have also been asked to pay a $90 copayment for an 
ER visit. An ER visit falls within the Emergency Care benefit category. You have been asked to pay a total of 
$130 ($40 copayment + $90 copayment = $130). This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for a 
hand x-ray and an emergency room (ER) visit provided from November 23, 2021, to November 24, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a knee x-ray provided on January 17, 2022. 
 
You asked the Plan to waive the copayment for an x-ray. You say that you have never been charged more than 
$50 for a specialist office visit. The Plan denied your request. The Plan says you have been charged the correct 
cost sharing amount 
 
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 $50 
copayment for an in-network x-ray. The Plan contract also says that if you have an office visit and your doctor 
requests radiology services, cost sharing may apply to each service. 
 
According to the EOC, a separate cost share amount applies to radiology services requested during an office 
visit. You have been asked to pay a $50 copayment for an x-ray. An x-ray falls within the Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation 
you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive 
the copayment for a knee x-ray provided on January 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on September 14, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this claim has not been billed in 
accordance with Medicare coding regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided 
that the Plan does not have to pay for the laboratory services provided on September 14, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve addition, endoskeletal system, below knee, alignable system 
(L5910). 
 
You asked the Plan to pre-approve the alignable system. You say that the alignable system addition is 
absolutely necessary for the entire prosthesis to function properly. The Plan denied your request. The Plan says 
that the preparatory prosthesis is a non-alignable system, therefore, the medical necessity for the requested 
alignable system is not met. 
 
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 pre-approve the alignable system. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee demonstrates K2-level ambulatory ability/potential due to his pre-amputation 
function. He has a strong desire to ambulate. Current presentation supports potential for full-time utilization 
and dependence upon a prosthesis for safety in mobility. Total contact will be used to eliminate single-point 
pressures. Ultra-lightweight components will be used to lessen prosthesis weight while not jeopardizing 
strength. Below knee alignable system is specified to ensure proper alignment and function. It is anticipated 
that 2 test sockets will be utilized to ensure appropriate fit, total contact, and alignment is achieved during the 
fitting process.  He was evaluated for the start of the prosthetic fitting process. After evaluation he was 
recommended to have an L5540 prosthetic with additions of endoskeletal system, below knee, alignable system 
(L5910) and addition to lower extremity, below knee, total contact (L5637). The additions are necessary to 
ensure proper alignment and function. The requested L5910 is not a listed code that is not covered. Therefore, 
the medical records provided do meet the requirements listed in the LCD for Medicare coverage. 
 
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 alignable system have been met. Therefore, we decided that the Plan has to 
pre-approve addition, endoskeletal system, below knee, alignable system (L5910).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex Superion interspinous spacer device. 
 
You asked the Plan to pre-approve the spacer device. The Plan denied your request. The Plan says this is 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 pre-approve the spacer device. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the Vertiflex spacer is experimental. More research is needed for this device. 
 
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 spacer device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the Vertiflex Superion interspinous spacer device.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive or reduce the cost share for the injection services provided on
August 2, 2021.
You asked the Plan to waive this cost share. You say that you do not believe this cost share is correct. The Plan
denied your request. The Plan says this cost share was charged based on the services provided and the Plan
contract agreement. Maximus partially overturned the Plans denial. The Plan requested a reopen and stated that
Maximus did not apply the correct contract language.
The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all
cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan
clearly says that you must pay 20% coinsurance for Medicare Part B drugs. The injection provided qualifies as
a Medicare Part B drug.
You have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan
does not have to waive to waive the cost share for the injection services provided on August 2, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission to be 
provided by an out-of-network (OON) provider/facility. 
 
You asked the Plan to pre-approve a SNF admission. You say that the requested facility has excellent 
therapists, and the enrollee has family and friends that work there that can contribute to his well-being. The 
Plan denied your request. The Plan says the enrollee must use a network provider to get medical care and 
services. The only exceptions are emergencies, urgently needed services when the network is not available 
(generally, when you are out of the area), out-of-area dialysis services, and cases in which the plan authorizes 
use of out-of-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 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 
a skilled nursing facility (SNF) admission to be provided by an out-of-network (OON) provider/facility.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical trays (A4550) provided on December 21, 2021. 
 
You asked the Plan to pay for the surgical trays. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says code A4550 cannot be billed with the revenue 
code 0270. 
 
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 A4550 is not supported in the record. Specifically, CPT code A4550 is not recognized 
under OPPS when billed on an outpatient hospital Part B bill type. Based on this information, we decided that 
Medicare rules for coverage of the surgical trays have not been met. Therefore, we decided that the Plan does 
not have to pay for the surgical trays (A4550) provided on December 21, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for ambulance services provided on April 13, 
2021. 
 
You asked the Plan to reduce the cost share for ambulance services. You say that the deductible should be 
applied to the 2021 benefit year. You also say if the deductible was met then you should be refunded for the 
difference. The Plan denied your request. The Plan says you have been charged the correct cost sharing 
amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $750 deductible which applies to ambulance services for treatment and 
no transport.  
 
The record shows you had not met your 2021 yearly plan deductible prior to receiving ambulance services on 
April 13, 2021. The item or service you asked the Plan to reduce the cost share for falls within the Ambulance 
Services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there 
is $750 deductible which applies to ambulance services for treatment and no transport. This cost sharing is a 
contractual obligation that had not been met at the time ambulance services was received on April 13, 2021. 
Therefore, we decided that the Plan does not have to reduce the cost share for ambulance services provided on 
April 13, 2021.