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

 
We decided that the Plan does not have to provide routine transportation to a destination which is 90 miles 
away. 
 
You asked the Plan to provide routine transportation. You say that you need this transportation in order to see 
this provider for necessary care. The Plan denied your request. The Plan says your transportation benefit can 
provide transportation to plan-approved locations within 50 miles of driving distance. The requested location is 
90 miles away, which exceeds the limitations of your benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers routine transportation to plan-approved locations within 50 miles of driving distance.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to provide routine transportation to a destination which is 90 miles away.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tier exception for Tacrolimus. 
 
You asked the Plan to pre-approve a tier exception for Tacrolimus. You say that the exception is needed. The 
Plan denied your request. The Plan says the drug does not qualify for tier exceptions. 
 
The Plan must follow Medicare rules. Medicare rules say that tiered cost-sharing means a process of grouping 
Part D drugs into different cost sharing levels within a Part D sponsor's formulary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a tier exception for Tacrolimus have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a tier exception for Tacrolimus.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an emergency alert system. 
 
You asked the Plan to pre-approve an emergency alert system. You say that this is medically necessary. The 
Plan denied your request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve an emergency alert system.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator (L8680, 63650). 
 
You asked the Plan to pre-approve the spinal cord stimulator. You say that the stimulator implant is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that performance and documentation of an effective trial 
is a prerequisite for permanent nerve stimulation. 
 
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 spinal cord stimulator. Our reviewer 
says that the requested service is not medically necessary. Our physician reviewer found there is no 
documentation of a successful trial of a spinal cord stimulator with pain relief. More documentation is required 
to support this request. 
 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 spinal cord stimulator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a spinal cord stimulator (L8680, 63650).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies. 
 
You asked the Plan to pre-approve a CGM and supplies. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the enrollee does not meet criteria for the requested item. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
continuous glucose monitor (CGM) and supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve a power scooter. You say that you feel it is wrong for the Plan to deny 
access for a scooter due to the condition your legs are in. The Plan denied your request. The Plan says you do 
not meet criteria for the requested device. 
 
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.  
 
The file shows that your condition can be improved by a cane. This means that Medicare rules for coverage of 
a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a power scooter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2311, 
E2313, E2377). 
 
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied 
your request. The Plan says your upper limb strength and function are adequate for the member to be able to 
control the power options using their own switches which are included in the allowance of these power options. 
 
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 accessories. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that you are independent with eating and contact guard assist for transfers. You have sufficient 
upper extremity strength to operate multiple standard power drive switches. 
 
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 accessories have not been met. Therefore, we decided that the Plan does not 
have to pre-approve additional power wheelchair accessories (E2311, E2313, E2377).
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to reduce the copayment for an outpatient hospital surgery visit. We decided that 
the Plan does not have to waive the copayment for an outpatient hospital wound visit.  
 You asked the Plan to waive the copayment for an outpatient hospital surgery visit provided from April 8, 
2022, to April 22, 2022. You say that you are appealing this copayment because you believe this is an error as 
you did not have minor surgery. The Plan says that this cost sharing was charged correctly. 
 
We decided that the Plan has to reduce the copayment for an outpatient hospital surgery visit.  
 
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost sharing information 
(such as copayments, deductibles and coinsurance). The Plan charged a $250 copayment for a surgery 
performed at outpatient hospital facility. However, the visit was billed by the provider with code 97597, which 
is a wound care code and not a surgical code. The Plans contract clearly states a wound care visit performed at 
an outpatient hospital facility is a $40 copayment. 
 
Therefore, we decided that the Plan has to reduce the copayment for an outpatient hospital surgery visit.  
 
We also decided that the Plan does not have to waive the copayment for an outpatient hospital wound 
visit. 
 
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 outpatient hospital wound visit. Therefore, we decided that the Plan does not have to waive 
the copayment for an outpatient hospital wound visit. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a powered upper extremity range of motion assist 
device, elbow, wrist, hand, finer, single or double upright (s), includes microprocessor, sensors, all components 
and accessories, custom fabricated. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says this device is contraindicated for people with rigid spasticity in the affected muscle 
groups. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that this device has not been shown to be reliably effective 4 years post-stroke, is not effective in 
presence of spasticity and is only endorsed from the American Heart Association as a tool for enhanced therapy 
not as a device to allow activities of daily living performance when the arm has not responded years after a 
stroke. 
 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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a powered upper extremity range of motion assist device, elbow, wrist, hand, finer, single or 
double upright (s), includes microprocessor, sensors, all components and accessories, custom fabricated.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vivity intra-ocular lenses (IOLs) to be inserted at the 
time of cataract surgery. 
 
You asked the Plan to pre-approve Vivity IOLs to be inserted at the time of cataract surgery. You say that the 
enrollee needs this type of lens for their type of vision. The Plan denied your request. The Plan says the 
requested services are not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives a P-C IOL 
during cataract surgery, the enrollee will be responsible for the difference in cost between the P-C IOL and a 
conventional IOL.  
 
The requested Vivity IOL is a type of presbyobia-correcting IOL. While an A-C IOL may be appropriate for 
the enrollee, neither the Plan nor Medicare covers the presbyobia -correcting feature of an IOL. Therefore, we 
decided that the Plan does not have to pre-approve Vivity intra-ocular lenses (IOLs) to be inserted at the time 
of cataract surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Coretext injections. 
 
You asked the Plan to pre-approve the injections. You say that this is medically necessary. The Plan denied 
your request. The Plan says the use of skin substitutes for Achilles tendonitis is not supported. 
 
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 injections. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that this injection is considered experimental/ investigational for Achilles tendonitis. Therefore, 
the request is deemed 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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Coretext injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electrical non-invasive osteogenesis stimulator 
(E0747). 
 
You asked the Plan to pre-approve an osteogenesis stimulator. You say that the requested item is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for an osteogenesis 
stimulator have not been met. 
 
The Plan must follow Medicare rules. The rules say that an electrical bone stimulator is covered for failed 
fusion where a minimum of 9 months has elapsed since the last surgery.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an osteogenesis stimulator have not been met. Specifically, the medical documentation does not 
support that the enrollee's last surgery was a minimum of 9 months ago. Therefore, we decided that the Plan 
does not have to pre-approve an electrical non-invasive osteogenesis stimulator (E0747).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a CGM. You say that the enrollee will not complete finger sticks. You also 
say that the enrollee was excited when they were informed that a Dexcom was an option. The Plan denied your 
request. The Plan says the enrollee does not meet criteria for the requested device. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor (CGM).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service February 24, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the records support the services should be 
separately reimbursed and the claim should be reprocessed for payment. 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 February 24, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance external mobile cardiovascular telemetry with 
electrocardiographic (ECG) provided on June 1, 2022. 
 
You asked the Plan to waive the coinsurance external mobile cardiovascular telemetry with ECG. You say that 
you feel you should not be responsible because it took off her skin and made her bleed, so you returned the 
equipment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for outpatient diagnostic tests.  
 
You have been asked to pay a 20% coinsurance for external mobile cardiovascular telemetry with ECG. The 
total allowed amount for the items is $987.96. You are being asked to pay $197.59 ($987.96 x 20% = $197.59)   
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 coinsurance external mobile cardiovascular telemetry with 
electrocardiographic (ECG) provided on June 1, 2022.  
 
Maximus read your letter and knows that you may have a quality of care concern. Maximus cannot address 
quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement 
Organization for further review.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Direct skilled nursing services of a registered nurse (RN) in 
the home health or hospice setting (G0299) Hospice or home health care provided in patient's home/residence 
Q5001) provided January 31, 2022, to March 1, 2022. 
 
You asked the Plan to pay for the home health services. You say that please process the claim. This is not a 
new SOC and does not need an NOA per Medicare guidelines. The Plan denied your request. The Plan says 
NOA required to process the claim. The provider did not bill as required by Medicare coding regulations. 
 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 find that CPT code G0299 and Q5001 is not supported in the medical record. Specifically, per 
the above guidelines the 30-day period of care claim was denied as a required data element for submission of 
claims under home health PPS was billed invalid. Per members claims history, a NOA claim with a one-time, 
artificial 'admission' date was billed and reported for January 01, 2022. The subsequent reporting of the 
admission/start of care date on this 30-day period of care claim was reported as December 02, 2021. Therefore, 
as the required data element, admission/start of care date on this subsequent 30-day period of care claim does 
not match the one-time, artificial 'admission' date from the NOA claim for the first period of continuing care in 
2022. Based on this information, we decided that Medicare rules for coverage of the home health services have 
not been met. Therefore, we decided that the Plan does not have to pay for Direct skilled nursing services of a 
registered nurse (RN) in the home health or hospice setting (G0299) Hospice or home health care provided in 
patient's home/residence Q5001) provided January 31, 2022, to March 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on June 9, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that these services were necessary 
and should be paid. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-
related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on June 9, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Power operated vehicle, group 2 standard, patient 
weight capacity up to and including 300 pounds (K0806). 
 
You asked the Plan to pre-approve the power wheelchair. You say that you are unable to walk from your 
bedroom to your living room without panting for air. You have fallen 3 times in the last few weeks. The Plan 
denied your request. The Plan says the specific power operated vehicle requested is specifically not covered by 
Medicare. 
 
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.  
 The file shows that Group 2 POVs (K0806, K0807, K0808) have added capabilities that are not needed for use 
in the home. Therefore, if a Group 2 POV is provided it will be denied as not reasonable and necessary. This 
means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Power operated vehicle, group 2 standard, patient weight capacity up to and including 
300 pounds (K0806).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the F2 gene analysis (81240) and F5 gene analysis 
(81241). 
 
You asked the Plan to pre-approve F2 and F5 gene analysis. You say that you need this service. The Plan 
denied your request. The Plan says this service is not covered for enrollees who are not pregnant. 
 
The Plan must follow Medicare rules. Medicare rules say that genetic testing for F5 and F2 genes are non-
covered except for pregnant patients.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of F2 and F5 gene analysis have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the F2 gene analysis (81240) and F5 gene analysis (81241).