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

 
We decided that the Plan does not have to pay for transtelephonic rhythm strip pacemaker evaluation provided 
on April 5, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for transtelephonic rhythm strip pacemaker evaluation. You say that you would like 
to request reconsideration of the denied claim. The Plan denied your request. The Plan says the provider is out-
of-network and authorization is required prior to an out-of-network visit. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for transtelephonic rhythm strip pacemaker evaluation 
provided on April 5, 2022, 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 continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the requested CGM. You say that it is felt that the CGM would be 
beneficial. The Plan denied your request. The Plan says Medicare criteria for the CGM are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily administrations. The record indicates that the enrollee injects 15 units of insulin once per day. Based on this information, we decided that Medicare rules for coverage of the requested CGM have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous 
glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intravenous infusion, for therapy, prophylaxis, or 
diagnosis provided on February 4, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an intravenous infusion, for therapy, prophylaxis, or diagnosis. You say that you 
would like to request reconsideration for payment. The Plan denied your request. The Plan says the provider is 
out-of-network, and it was determined these services can be received in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an intravenous infusion, for therapy, prophylaxis, 
or diagnosis provided on February 4, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Abilitech assist orthotic device. 
 
You asked the Plan to pre-approve Abilitech assist orthotic device. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the requested item 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 Abilitech assist orthotic device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has a past medical history of transverse myelitis with 
quadriplegia. Based on the medical records provided and current clinical guidelines there is no documentation 
that the Abilitech Assist orthotic device at issue in this case meets Medicare criteria for medically reasonable 
and necessary. Current clinical guidelines designate robotic therapy to be of "uncertain utility compared with 
dose-matched conventional upper limb exercise therapies" with unproven benefit in the home environment. 
Although records from the device manufacturer/vendor argue medical necessity of the requested device, no 
records from the enrollees actual treating provider clarify why the requested device is the most appropriate 
treatment for the enrollees condition. Therefore, the enrollee does not meet criteria for the requested 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 Abilitech assist orthotic device have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Abilitech assist orthotic device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electrical stimulation (G0283) and ultrasound therapy 
(97035) performed by a chiropractor on April 8, 2022. 
 
You asked the Plan to pay for electrical stimulation and ultrasound therapy. You say that these two healing 
techniques were critical for your healing process. The Plan denied your request. The Plan says physical therapy 
services are not covered when performed by a chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
 
  The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for electrical stimulation (G0283) and ultrasound therapy (97035) performed by a 
chiropractor on April 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy-duty manual wheelchair (K0006). 
 
You asked the Plan to pre-approve a heavy-duty manual wheelchair (K0006). You say that the requested heavy 
duty manual wheelchair (K0006) is medically necessary. The Plan denied your request. The Plan says the 
enrollee does not meet criteria for the requested heavy duty manual wheelchair (K0006). 
 
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 heavy-duty manual wheelchair 
(K0006). Our reviewer says that the enrollee does not meet criteria for the requested heavy-duty manual 
wheelchair (K0006). Our physician reviewer found based on the medical records provided there is no 
documentation that the heavy-duty manual wheelchair (K0006) at issue in this case meets Medicare/LCD 
criteria. Provided records do not clearly document all the factors as required by the LCD. 
 
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 heavy-duty manual wheelchair (K0006) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a heavy-duty manual wheelchair (K0006).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve therapeutic CGM. You say that you are legally blind and cannot use a 
OneTouch brand device. The Plan denied your request. The Plan says you do not meet the Medicare criteria for 
a therapeutic 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 you do not perform blood glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with your 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of therapeutic CGM have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oxygen accessory, battery pack/cartridge for a 
portable oxygen concentrator (POC), any type, replacement only, each (E1356). 
 
You asked the Plan to pre-approve an extra battery pack/cartridge for a POC. You say that you are oxygen 
dependent and need the extra battery pack for your oxygen concentrator. The Plan denied your request. The 
Plan says Medicare does not provide coverage for POC batteries as the item itself, the POC, can be recharged. 
When a POC is authorized, it includes the device itself, and an integrated battery or beneficiary-replaceable 
battery. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an extra battery pack/cartridge for POC have not been met. The records show that Medicare does 
not cover an extra set of batteries. Therefore, we decided that the Plan does not have to pre-approve an oxygen 
accessory, battery pack/cartridge for a portable oxygen concentrator (POC), any type, replacement only, each 
(E1356).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for ExoDx prostate genetic testing.
You asked the Plan to provide coverage for this testing. You say that this testing is medically necessary. The Plan denied your request. The Plan says this testing is not covered by Medicare. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not review the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for ExoDx prostate genetic testing. The Maximus Physician Reviewer determined that this urine exosome gene expression assay is a noninvasive, urinary 3-gene expression assay that discriminates high-grade (GS7) from low-grade (GS6) cancer and benign disease. In this study, the urine exosome gene expression assay was associated with improved identification of patients with higher-grade prostate cancer among men with elevated PSA levels and could reduce the total number of unnecessary biopsies. It was decided that the Medicare rules for coverage of the service were met. The Plan requested a reopen and argues that although there are studies that demonstrate a benefit to this modality (as cited by the Maximus reviewer), there are also studies that demonstrate no benefit. As such, it is inappropriate to annotate a single study and use it as demonstrative proof that a test is medically necessary in the absence of applicable Medicare Guidelines.
The Plan states that they followed appropriate Medicare guidance in establishing criteria for the denial. "It must be pointed out that the criteria used evaluated numerous studies to make the determination and not just one study. As far as evidence-based medicine guidelines are concerned, this is the appropriate hierarchy as using a single study to support a position is erroneous." The medical records show BPH with nocturia and an elevated PSA. The urologic oncology note documents a digital rectal exam without significant abnormality. ExoDx was ordered. However, the plan is correct in this case. ExoDx prostate genetic testing does not have FDA-approval or FDA-clearance. There is insufficient evidence to support that this genetic testing reliably impacts patient management and outcomes. The records do not support that the genetic testing in this case was medically 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 this testing have not been met. Therefore, we decided that the Plan does not have to provide coverage for ExoDx prostate genetic testing.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service April 8, 
2022. 
 
You asked the Plan to pay for procedure code 76705. You say that the enrollee had multiple exams on the date 
in question. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976. 
 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 76705 
is a column II code to column I code 93976. 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 76705 billed for date of service April 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6549. 
 
You asked the Plan to pre-approve the compression stockings. You say that these stockings are needed every 6 
months. The Plan denied your request. The Plan says these stockings are not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6549.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 11, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the office services are denied because we need an 
approved referral from your primary care physician. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on March 11, 2022, by an 
out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ankle foot orthosis and addition to lower extremity 
orthosis provided on April 7, 2022. 
 
You asked the Plan to pay for the ankle foot orthosis and addition to lower extremity orthosis. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the items rendered are not 
supported by the documentation. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.   
The record does not contain a valid proof of delivery for the supplies provided in this case. The documentation 
did not include a valid proof of delivery or a delivery ticket to indicate the specific supplies rendered. The 
record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for the ankle foot orthosis and addition to lower 
extremity orthosis provided on April 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on March 28, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says the provider is out-of-
network, and it was determined these services can be received in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for subsequent nursing facility care provided on 
March 28, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Intracept surgery. 
 
You asked the Plan to pre-approve Intracept surgery. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested services are 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 Intracept surgery. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has back pain. The Intracept procedure is experimental for back pain. 
More research is needed. Therefore, the enrollee does not meet criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Intracept surgery have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Intracept surgery.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 24, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams on the date 
in question. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service 
March 24, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response and treatment, no transport provided on 
January 20, 2022. 
 
You asked the Plan to pay for ambulance response and treatment, no transport. You say that the services should 
be covered. The Plan denied your request. The Plan says the ambulance benefit is a transportation benefit. 
When there is no transport, neither Medicare nor the Plan pays for the services provided. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on January 20, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport 
provided on January 20, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Percutaneous implantation of neurostimulator electrode 
array; peripheral nerve (excludes sacral nerve) (64555) and Insertion or replacement of peripheral or gastric 
neurostimulator pulse generator or receiver, direct or inductive coupling (64590) for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that the enrollee failed conventional treatment. The 
Plan denied your request. The Plan says that there is a lack of literature evaluating long-term efficacy and 
adverse events associated with implantable peripheral nerve stimulation devices. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. There is a lack of 
data supporting the long term outcome of this device. It is considered experimental/investigational at this time. 
Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these services. 
 
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 Percutaneous implantation of neurostimulator 
electrode array; peripheral nerve (excludes sacral nerve) (64555) and Insertion or replacement of peripheral or 
gastric neurostimulator pulse generator or receiver, direct or inductive coupling (64590) for the enrollee.