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

We decided that the Plan does not have to provide coverage for an E2377 Expandable Controller, E2313 Expandable Controller Harness, and E2311 Electronic Connection for the enrollee.
You asked the Plan to provide coverage for these accessories. You say that at the time of the appeal, these accessories were medically necessary. The Plan denied your request. The Plan says Medicare criteria for an E2377 Expandable Controller, E2313 Expandable Controller Harness, and E2311 Electronic Connection were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not use the correct criteria.
The Plan notes that the medical record clearly states the enrollee has a T6 spinal cord injury and that the enrollee is a paraplegic, not tetraplegic. The records show the enrollee would be able to activate the switch that was included with the approved wheelchair. The records show the enrollee's upper limb strength and function are adequate to control the power options using their own switches which are included in the allowance of these power options.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare has specific coverage criteria for the requested accessories. Medicare does not cover equipment that exceeds an enrollee's needs or is duplicate to an accessory already included in a prior approval. Based on the records provided, the original Maximus reviewer agreed with the conclusion that the enrollee is not a tetraplegic. The denied accessories exceed the enrollees' medical needs. Therefore, we decided that the Plan does not have to provide coverage for an E2377 Expandable Controller, E2313 Expandable Controller Harness, and E2311 Electronic Connection for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for Durysta (Bimatoprost).
You asked the Plan to provide coverage for this drug. You say that this drug is medically necessary. The Plan
denied your request. The Plan says Medicare coverage criteria were not met. Maximus overturned the Plans
denial. The Plan requested a reopen and provided additional information.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for Durysta
(Bimatoprost). The Maximus Physician Reviewer determined that Durysta received FDA approval in March
2020, to reduce intraocular pressure in patients with open angle glaucoma. The Plan requested a reopen and
stated that while the enrollee does have open angle glaucoma and would normally qualify for the Durysta
implant for treatment, she also has Fuch's dystrophy. The Plan notes that the FDA labeling document for the
Durysta states in section 4.2 that Durysta is contraindicated in patients with corneal endothelial cell dystrophy
(e.g., Fuchs' Dystrophy). The section Warning and Precautions, sub-section 5.1 Corneal Adverse Reactions, it
states that the presence of Durysta implants has been associated with corneal adverse reactions and increased
risk of corneal endothelial cell loss. Administration of Durysta should be limited to a single implant per eye
without retreatment. Caution should be used when prescribing Durysta in patients with limited corneal
endothelial cell reserve. The medical records show the enrollee is a 72-year-old woman with bilateral Primary
Open Angle Glaucoma.
The record indicates diagnosis of open angle glaucoma in the setting of corneal endothelial cell dystrophy (e.g.,
Fuchs' Dystrophy.) The Food and Drug Administration has stated that the requested drug is contraindicated in
the setting of corneal endothelial cell dystrophy (e.g., Fuchs' Dystrophy.) The Medicare approved drug
compendia do not contain a supportive citation for the use of the requested drug in the enrollee's specific
clinical situation. The elements of the coverage criteria are not satisfied. The requested service cannot be
recommended. The Plan is correct in this case. The FDA-approved label states, "DURYSTA is contraindicated
in patients with corneal endothelial cell dystrophy (e.g., Fuchs' Dystrophy)".
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 drug have not been met. Therefore, we decided that the Plan does not have
to provide coverage for Durysta (Bimatoprost).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Optimizer Smart Device for cardiac contractility 
modulation (CCM). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the 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 these services. 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 left ventricular dysfunction and continued symptoms, despite medical 
treatment, thought to reflect congestive heart failure. While the clinical studies led to Food and Drug 
Administration (FDA) approval in 2019, CCM remains the subject of multiple studies examining long-term 
efficacy, as well as randomized, controlled, double-blinded trials to quantify clinical efficacy. Until such 
statistically rigorous studies are completed, it is premature to presume clinical outcomes and benefit. The CCM 
system is not medically necessary at this time. 
 
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 an Optimizer Smart Device for cardiac contractility modulation (CCM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (tens) device, 
four or more leads, for multiple nerve stimulation (E0730) provided May 28, 2022. 
 
You asked the Plan to pay for the TENS device. You say that note that according to the enrollee's prescription, 
the prescribing physician recommends an extended, lifetime use of equipment as they are diagnosed with 
chronic pain and compromised mobility without the option for surgical correction. The Plan denied your 
request. The Plan says the information submitted does not support this level of service. 
 
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, or relevant medical records which support medical 
necessity for the supplies provided in this case. Specifically, the provider did not submit the proof of delivery 
or a delivery ticket. 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 
transcutaneous electrical nerve stimulation (tens) device, four or more leads, for multiple nerve stimulation 
(E0730) provided May 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) 
device provided on June 8, 2022. 
 
You asked the Plan to pay for the TENS device. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the item rendered is not supported. 
 
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. Review of the file 
shows that the documentation did not include a valid proof of delivery or a delivery ticket. The tracking 
numbers on the delivery ticket shows that the label was created, but not yet in the system. This means there is 
no proof of delivery. 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 
transcutaneous electrical nerve stimulation (TENS) device provided on June 8, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the colonoscopy (45378) provided on June 3, 2022. 
 
You asked the Plan to pay for the colonoscopy. You say that you are hopeful this insurance company will still 
accept the claim and make some payment pending a determination of responsibility from your primary 
insurance company. The Plan denied your request. The Plan says the claim cannot be processed towards the 
benefits until the explanation of benefits is received from your primary insurance company. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
 
 
 The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has requested the 
Explanation of Benefits (EOB) multiple times with no success. As the secondary insurer, the Plan cannot be 
held responsible for the colonoscopy until the primary insurer has denied the claim for these services. 
Therefore, we decided that the Plan does not have to pay for the colonoscopy (45378) provided on June 3, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for CT scan provided on April 26, 2022. 
 
You asked the Plan to waive the copayment for CT scan. You say that you are disputing the share cost. 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 $375 
copayment for outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay $375 copayment for CT scan. This item/service 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 CT scan provided on April 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on October 19, 2020. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for 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. The claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for lab services provided on October 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64483 billed for date of service May 10, 
2022. 
 You asked the Plan to pay for procedure code 64483. You say that this was the patient's first injection and you 
were unaware of the patient receiving other treatment. The Plan denied your request. The Plan says the number 
of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 64483 is 1. The MAI value for this code is 2. You billed 2 units of this 
code instead of billing one unit with a bilateral modifier, exceeding the MUE. Based on this information, we 
decided that Medicare rules for coverage of procedure code 64483 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure code 64483 billed for date of service May 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (80307, 82542, 84228 and G0480) 
provided on July 8, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that these services were medically necessary. The 
Plan denied your request. The Plan says these services were not performed by or referred by a network 
provider. Out-of-network services are covered only in certain limited circumstances which have not been met 
in this case. 
 
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 laboratory services (80307, 82542, 84228 and 
G0480) provided on July 8, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMs Heart Failure system. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the CardioMEMS device was approved 
by the Food and Drug Administration (FDA) in 2014; however, subsequent follow-up studies remain 
encouraging and suggest an improvement in heart failure symptoms with the use of the device. In addition, 
published expert opinion in the cardiology literature is supportive of the clinical usefulness of CardioMEMS. 
Nonetheless, there remains a dearth of randomized, blinded clinical studies examining long-term clinical 
outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the 
CardioMEMS system would not be considered medically appropriate 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a CardioMEMs Heart Failure system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9379 billed for date of service May 31, 
2022. 
 
You asked the Plan to pay for procedure code S9379. The Plan denied your request. The Plan says the billed 
code is invalid for Medicare purposes. 
 
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 S9379 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9379 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9379 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9379 billed for date of service May 31, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that daily skilled services are not required. There is no documentation that the 
enrollee requires services on an inpatient basis, only in a skilled nursing facility setting. The enrollees care 
needs can, as a practical matter, be provided at a lower level of 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on April 8, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this testing was not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the testing. Our reviewer says that the 
requested services were not considered medically reasonable and necessary in this case. Our physician reviewer 
found that it was not clear how the treatment plan would have changed based on any results of the Guardant360 
testing as the enrollee agreed to do Xtandi and continued Eligard and androgen deprivation therapy. This 
testing method is newer and not yet supported by high quality studies showing low risk or clinically significant 
benefit over the standard of care for this enrollee 's condition. Therefore, this request for Guardant360 testing will be considered not medically reasonable or necessary at this time. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the Guardant360 testing provided on April 8, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you just had a hip replacement and cannot go home. 
You say you cannot safely exist at home in your condition. The Plan denied your request. The Plan says the 
IRF admission you are requesting does not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. 
 
 Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require 
an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You continue to 
have a need for skilled therapy with ongoing safety concerns and a potential for functional improvement 
however, the documentation doesnt support that you meet criteria for admission to an acute inpatient 
rehabilitation facility. You can receive further services at a lower level of 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 IRF admission and services.
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 at the time of the appeal, IRF admission was
medically necessary. The Plan denied your request. The Plan says 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 IRF services.
The Maximus Physician Reviewer determined that admission was necessary. The Plan requested a reopen and
argues based on the enrollee's level of function, she did not require an intensive, complex, multidisciplinary
approach to daily therapy. The Plan also notes that "the discharge summary clearly documents physical therapy
recommended SNF placement."
The Plan is correct in this case. 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. The discharge summary documented, "Physical therapy evaluated with
recommendation for SNF. She is medically stable for discharge to SNF."
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.