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

We decided that the Plan does not have to pay for the testing (81455) provided to the enrollee on December 28, 2021.
You asked the Plan to pay for the testing. You say that the testing was medically necessary. The Plan denied
your request. The Plan says that this sample was not taken by the laboratory directly.
Maximus overturned the Plans denial. The Plan requested a reopen and stated the issue was not medical
necessity issue but the fact that the claim was submitted with an error. 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 specimen
was not collected in an independent laboratory.
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. In this case, this claim
cannot be paid as billed due to error with the POS code reported. Medicare rules for coverage of this testing
have not been met. Therefore, we decided that the Plan does not have to pay for the testing (81455) provided to
the enrollee on December 28, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ten (10) additional physical therapy (PT) sessions.
You asked the Plan to pre-approve the therapy services. You say that additional PT sessions are medically
necessary. The Plan denied your request. The Plan says that the medical criteria for additional PT has not been
met.
Our Medical director looked at the case file and the reopen request. At issue is coverage for ten (10) additional
physical therapy (PT) sessions. Our Medical Director states that the documentation is insufficient to
demonstrate that the enrollee needed the continued skills of a physical therapist, and that the duration of
services was reasonable under accepted standards of practice.
Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of the therapy
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 the therapy services have not been met. Therefore, we decided that the Plan
does not have to pre-approve ten (10) additional physical therapy (PT) sessions.
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for PrismRA molecular testing provided on March 16, 2022.
You asked the Plan to pay for this testing. You say that this testing should be covered by the Plan. The Plan
denied your request. The Plan says the Medicare coverage criteria were not met. Maximus overturned the Plans
denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for PrismRA
molecular testing. The Maximus Physician Reviewer found the testing was medically necessary. The Plan
requested a reopen and notes PrismRA testing, and the interpretive content have not been reviewed, cleared, or
approved by the FDA. The medical records show the enrollee has a diagnosis of Rheumatoid arthritis (RA)
without rheumatoid factor. Only the test results were submitted by the provider. No additional clinical records
are provided. In addition, no clinical studies provide sufficient evidence supporting this testing improves RA
symptoms and treatment response. The Plan is correct in this case as medical necessity for this testing has not
been established. We looked at this physician's review, the file, and Medicare rules. Based on this information,
Medicare rules for coverage of this testing were not met. Therefore, we decided the Plan does not have to pay
for PrismRA testing provided on March 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a power scooter.
You asked the Plan to provide coverage for a power scooter. You say that at the time of the appeal a power
scooter was medically necessary. The Plan denied your request. The Plan says the Medicare coverage criteria
are not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did
not apply the correct criteria.
The Plan follows Medicare rules. Medicare rules say that a power mobility device such as a power scooter will
not be covered if the enrollee does not have mobility deficit that impairs their participation in MRADLs, the
enrollee's condition can be ameliorated by a walker, cane or manual wheelchair, or the enrollee is not capable
of safely operating the requested device. The medical records provided show the power mobility device
evaluation states you are independent with activities of daily living in the home and that you do not meet the
criteria required for the requested power mobility device. The evaluation recommends a manual wheelchair for
your living environment. Medicare rules for coverage for a power scooter were not met. Therefore, we decided
that the Plan does not have to provide coverage for a power scooter.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services (11406 and 12032) provided to the
enrollee on November 8, 2021.
You asked the Plan to pay for the surgical services. You say that you would like the Plan to reconsider their
denial of payment. The Plan denied your request. The Plan says that the services are not covered as billed.
Maximus overturned the Plan's denial. The Plan requested a reopening on the basis of the claim missing a
required modifier. The Plan is correct in this case. Modifier -79 must be appended to indicate that these
services were unrelated to the original procedure during the postoperative period. Based on this information,
we decided that Medicare rules for coverage of the surgical services have not been met. Therefore, we decided
that the Plan does not have to pay for the surgical services (11406 and 12032) provided to the enrollee on
November 8, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve allograft (20930) for a spinal surgery. 
 
You asked the Plan to pre-approve allograft. You say that the requested services are a medical necessity for the 
enrollee. The Plan denied your request. The Plan says the requested services are experimental/investigational. 
 
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 allograft. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is limited published, large-scale, long-term, peer-reviewed literature that shows the requested 
allograft to be an effective and/or safe treatment for the enrollee's pathology. Further studies are needed to 
demonstrate that the requested allograft has beneficial outcomes compared with conventional treatment. There 
is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of allograft have not been met. Therefore, we decided that the Plan does not have 
to pre-approve allograft (20930) for a spinal surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99135 billed for date of service June 15, 
2022. 
 
You asked the Plan to pay for procedure code 99135. You say that the claim should be reviewed for payment. 
The Plan denied your request. The Plan says procedure codes 00670 and 36620 have been approved. The Plan 
also says procedure code 99135 is considered bundled and not separately payable. 
  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99135 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99135 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99135 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99135 billed for date of service June 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transit kit (K0108). 
 
You asked the Plan to pre-approve a transit kit. You say that the requested item is medically necessary. The 
Plan denied your request. The Plan says that a transit kit is for use outside the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a transit kit (K0108).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a swallowing function x-ray (CPT 74230), and upper 
gastrointestinal tract x-ray (CPT 74240) provided on September 9, 2022. 
 
You asked the Plan to pay for a swallowing function x-ray (CPT 74230), and upper gastrointestinal tract x-ray 
(CPT 74240). You say that the services were medically necessary. The Plan denied your request. The Plan says 
the services do not meet the Medicare coverage criteria. 
 
The Plan must follow Medicare rules.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a swallowing function x-ray (CPT 74230), and upper gastrointestinal tract x-ray (CPT 74240) have 
not been met. Therefore, we decided that the Plan does not have to pay for a swallowing function x-ray  
(CPT 74230), and upper gastrointestinal tract x-ray (CPT 74240) provided on September 9, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care associated with an elective 
surgery. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the enrollee is a poor candidate for 
physical therapy. The Plan denied your request. The Plan says there is no documentation provided to support 
the expectation the enrollee will require a greater than two midnight stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.   

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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that detailed documentation is not evident regarding a significant past and/or current 
medical history that would place this enrollee at increased risk for peri-surgical complications requiring an 
inpatient stay. There is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception. Therefore, the record does not show that at the time of 
inpatient admission, the admitting physician reasonable expected that the enrollee's necessary hospital care 
would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care associated with an elective surgery.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on June 7, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you were 
told the driver was on the way. You also say that it was getting to l ate to get to the surgery center so you drove 
yourself. The Plan denied your request. The Plan says these services are not a covered benefit. 
 
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 June 7, 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 the ambulance response and treatment with no 
transport provided on June 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power tilt seating system (E1002), power leg rests 
(E1012), an electronic connection (E2311) and an accessory bar (K0108) for a power wheelchair. 
 
You asked the Plan to pre-approve a power tilt seating system, power leg rests, an electronic connection and an 
accessory bar. You say that the requested items are a medical necessity for the enrollee. The Plan denied your 
request. The Plan says the request 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. The rules also say that for equipment to be covered, it must primarily serve a 
medical purpose. 
 
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 power tilt seating system, power leg 
rests and an electronic connection. Our reviewer says that the requested items are not medically reasonable and 
necessary in this case. Our physician reviewer found that the available documentation does not indicate that the 
enrollee has any pressure injuries or requires intermittent catheterization of the bladder that would necessitate 
power tilt. There is no indication that the enrollee requires power leg rests. The requested electrical accessories 
are not medically necessary as the enrollee does have use of the upper extremity and can operate and control 
the power options using the switches that are included in the basic wheelchair. 
 
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 power tilt seating system, power leg rests and an electronic connection have 
not been met. An accessory bar does not serve a purpose that is primarily medical in nature. Therefore, we 
decided that the Plan does not have to pre-approve a power tilt seating system (E1002), power leg rests 
(E1012), an electronic connection (E2311) and an accessory bar (K0108) for a power wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377), expandable harness 
(E2313), electronic connection between wheelchair controller and two or more power seating system motors 
(E2311) and push handles (K0108). 
 
You asked the Plan to pre-approve an expandable controller, expandable harness, electronic connection 
between wheelchair controller and two or more power seating system motors and push handles. You say that 
this power wheelchair is medically necessary. The Plan denied your request. The Plan says although there are 
three approved power options on this wheelchair (tilt, recline and elevating leg rests), there is not a 
medical need to control these power options through the joystick 
 
The Plan follows Medicare rules. Medicare rules say that these upgrades may be covered when the criteria 
listed in the rules section are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an expandable controller, expandable 
harness, electronic connection between wheelchair controller and two or more power seating system motors 
and push handles.. Our reviewer says that the requested PWC upgrades are not medically necessary. Our 
physician reviewer found that the enrollee has tetraplegia and is dependent for activities of daily living except 
feeding. The enrollee is able to use a standard joystick to manage wheelchair. The enrollee has adequate control 
and strength to manage multiple power drives. 
 
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 expandable controller, expandable harness, electronic connection between 
wheelchair controller and two or more power seating system motors and push handles have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377), 
expandable harness (E2313), electronic connection between wheelchair controller and two or more power 
seating system motors (E2311) and push handles (K0108).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection(s), anesthetic agent(s) and/or steroid; 
transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, each additional level 
(64484). 
 
You asked the Plan to pre-approve an injection. You say that you disagree with the denial and have provided 
medical records for review. The Plan denied your request. The Plan says the enrollee does not meet criteria for 
the additional injections. 
 
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 injections. 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 history of asthma, chronic obstructive pulmonary disease, diabetes mellitus, 
headaches, s/p C4-C6 fusion 2004 and 2015, s/p kyphoplasty for L2 compression fracture, and back and leg 
pain/lumbosacral radiculopathy. On February 17, 2023, the enrollee underwent therapeutic right L4 and L5 
selective nerve root blocks (SNRBs). On February 21, 2021, the enrollee reported 100% relief of her anterior 
thigh pain, but new numbness of anterior shin/anterior thigh pain and posterior thigh and calf pain.  She was 
seen again on February 27, 2023. The MRI showed a broad-based disc bulge at L1-2 with mild central canal 
stenosis, facet hypertrophy at L2-L3 and L3-L4 with no canal or foraminal stenosis at those levels, broad based 
disc bulging with facet hypertrophy and mild to moderate central canal stenosis at L4-L5, with bilateral facet 
hypertrophy at L5-S1. A physical exam on March 6, 2023, demonstrated reduced sensation at the L5 and S1 
dermatome. The right selective S1 SNRB meets the criteria established in the Medicare rules. However, based 
on LCD L38994 coverage criteria, the L5 SNRB 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 injections have not been met. Therefore, we decided that the Plan does not have 
to pre-approve injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance 
(fluoroscopy or CT), lumbar or sacral, each additional level (64484).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the use of bone marrow aspirate during an approved 
spinal surgery. 
 
You asked the Plan to pre-approve the bone marrow aspirate use. You say that it is felt that the services should 
be approved as requested. The Plan denied your request. The Plan says the use of bone marrow aspirate is 
considered experimental in this type of spinal surgery. 
 
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 bone marrow aspirate use. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found there is no specific indication provided to support the request for bone marrow 
aspirate for the approved surgery. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of bone marrow aspirate for this enrollees medical condition. There is no compelling rationale 
presented or extenuating circumstances noted to support the medical necessity of this request as an exception. 
Therefore, the requested bone marrow aspirate in the setting of spinal fusion, 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 bone marrow aspirate use have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the use of bone marrow aspirate during an approved spinal surgery.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two or more power seating system motors (E2311). 
 
You asked the Plan to pre-approve the DME. You say that the Group 3 power wheelchair is the only power 
wheelchair that can meet the enrollee's medical and functional needs. The Plan denied your request. The Plan 
says although there are more than two approved power options on this wheelchair, there is not a medical need 
to control these power options through the joystick. 
 
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 DME. 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 adequate upper body strength to manage standard switches on a power 
wheelchair. The request is not medically necessary to address enrollee's needs.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve two or more power seating system motors (E2311).