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

We decided that the Plan does not have to provide coverage for a K3 foot and Ossur Mauch K3 knee.
You asked the Plan to provide coverage for a K3 foot and Ossur Mauch K3 knee. You say that this equipment 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 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 a K3 foot and Ossur Mauch K3 knee. The Maximus Physician Reviewer found the requested foot and knee to be medically reasonable and necessary. The Plan requested a reopen and argues that while the ordering physician or practitioner states that you are expected to be K3 ambulator, the medical records do not support this statement. The records show you have been without a prosthesis for over a year. The initial amputation was June of 2021. The physician notes from June 7, 2022, state "Patient is currently at a wheelchair level but is expected to achieve a K3 level for ambulation". The medical records show you have an extensive medical history. At the time of the Orthopedic Center evaluation on June 7, 2022, you were not a K3 ambulator.
The Plan is correct in this case. The Medicare LCD L33787 states, "A microprocessor-controlled ankle foot system (L5973), energy storing foot (L5976), dynamic response foot with multi-axial ankle (L5979), flex foot system (L5980), flex-walk system or equal (L5981), or shank foot system with vertical loading pylon (L5987) is covered for beneficiaries whose functional level is 3 or above." In addition, an advanced electronic /microprocessor knee is only covered for beneficiaries at a K3 functional level. The clinical documentation does not support that you were a K3 ambulator at the time of the request. Medicare does not approve this equipment based on the "potential" to become a K3 ambulation. 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 equipment have not been met. Therefore, we decided that the Plan does not have to provide coverage for a K3 foot and Ossur Mauch K3 knee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you were told that the enrollee should be in skilled 
nursing care for two to three months. You say that the enrollee has only had physical therapy for one month, 
and you believe they can benefit from additional physical therapy. The Plan denied your request. The Plan says 
the criteria for a continued stay in the SNF has not been met. 
 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 the enrollee does not have identifiable skilled nursing or skilled therapy service 
needs. The enrollee does not require daily skilled nursing or skilled therapy on an inpatient basis in a SNF 
setting. 
 
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 continued SNF care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an electrocardiogram (93000) provided on 
June 16, 2022 
 
You asked the Plan to waive the copayment for the EKG. You say that the services should be covered as you 
disagree with the charges. 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 $45 
copayment for Outpatient diagnostic tests and therapeutic services and supplies.  
 
 
  You have been asked to pay a $15.16 copayment for the EKG, which is less than the standard $45. 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 an electrocardiogram (93000) provided on June 16, 2022
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial preventive physical examination (CPT code G0402) 
and hospital outpatient clinic visit for assessment and management of a patient (CPT code G0463) provided on 
June 9, 2022. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not covered as billed. 
 
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 the services have not been met. Review of the file shows the 
provider billed G0402 and G0463 on the same date of service with Revenue Code 0510, and per OCE Edit 42, 
a claim reported with multiple medical visits on the same date of service with same revenue code must include 
condition code G0. Therefore, we decided that the Plan does not have to pay for initial preventive physical 
examination (CPT code G0402) and hospital outpatient clinic visit for assessment and management of a patient 
(CPT code G0463) provided on June 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (0037U) provided on October 18, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 0037U is not supported in the medical record. Specifically, the date the specimen was 
obtained (September 29, 2021) does not match the date of service billed. 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 (0037U) provided on October 18, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tier exception for Yupelri. 
 
You asked the Plan to pre-approve a tier exception for Yupelri. 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. You can find this rule in 42 
CFR 423.4. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a tier exception for Yupelri have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a tier exception for Yupelri.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an fluorodeoxyglucose (FDG)-positron emission 
tomography (PET) scan 
 
You asked the Plan to pre-approve FDG PET scan. You say that the enrollee has memory decline with a 
concern that they may have Alzheimer's disease. You say that the previous PET scan was performed in 2021. 
You also say that another PET scan is necessary to measure the severity and progression of the disease. The 
Plan denied your request. The Plan says the requested service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that an FDG PET scan is considered reasonable and 
necessary in patients with a recent diagnosis of dementia and documented cognitive decline of at least 6 
months, who meet diagnostic criteria for both Alzheimer's Disease (AD) and fronto-temporal dementia (FTD). 
 
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 FDG PET scan. Our reviewer says that the requested FDG PET scan is not medically necessary. Our physician reviewer found the provided 
documentation does not indicate that the enrollee meets diagnostic criteria for both Alzheimer's Disease (AD) 
and fronto-temporal dementia (FTD). The reviewer found that this is a request for a second study. The reviewer 
also found that there was no diagnosis previously made of AD or FTD on prior imaging. Therefore, the 
reviewer found that the requested FDG PET scan is not medically 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 FDG PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an fluorodeoxyglucose (FDG)-positron emission tomography (PET) scan
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. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says an IRF admission is not medically necessary. 
 
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 enrollee's needs do not require intensive physician and nursing oversight in an 
IRF. 
 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM) 
 
You asked the Plan to pre-approve a Freestyle Libre 2 CGM. The Plan denied your request. The Plan says the 
enrollee does not meet the prior authorization criteria requirements for coverage. 
 
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 or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a Freestyle 
Libre 2 CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle 
Libre 2 continuous glucose monitor (CGM)
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. 
 
You asked the Plan to pre-approve IRF care. You say that the requested IRF admission is medically necessary. 
The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the 
enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitation care. The enrollee was admitted for weakness and cystitis. Medical problems are stable. There are no complex nursing or rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, in an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S2900 billed for date of service May 6, 2022. 
 
You asked the Plan to pay for procedure code S2900. You say that you have provided medical records to 
support payment. 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 S2900 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S2900 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S2900 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S2900 billed for date of service May 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 26, 2022, billed with 
multiple codes. 
 
You asked the Plan to pay for the genetic testing billed. You say that the services at issue have been billed 
correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using an NGS procedure, the laboratory shall report only one unit of service of one genomic sequencing 
procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or proprietary 
laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
April 26, 2022, billed with multiple codes.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urinalysis (CPT code 81015) provided on February 9, 
2021. 
 
You asked the Plan to pay for the urinalysis. You say that the claim should be paid. The Plan denied your 
request. The Plan says the service is not covered as billed. 
 
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 81015 
is a column II code to column I code 81000 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for the urinalysis (CPT code 81015) provided on February 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the eyeglasses provided on August 3, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you were told by the provider that the 
eyeglasses would be covered for your prescription change. The Plan denied your request. The Plan says your 
benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service March 23, 2021. 
Therefore, we decided that the Plan does not have to pay more for the eyeglasses provided on August 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prosthetic leg with an advanced foot and ankle feature 
(L5981, L5984). 
 
You asked the Plan to pre-approve prosthetics. You say that you have been an amputee for 24 years and are a 
K3 level ambulator. You have enclosed the prosthetist notes, ampro score and your functional level assessment 
from your physician. The Plan denied your request. The Plan says the request for a K3 foot does not meet 
Medicare criteria as reasonable and 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 prosthetics. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found per physician records; you are not a community ambulator without your walker. You are not a 
K3 ambulator. Per LCD 33787, the advanced prosthesis is covered for an independent community ambulator 
who does not rely in a walker. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of prosthetics have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a prosthetic leg with an advanced foot and ankle feature (L5981, L5984).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox (J0585). 
 
You asked the Plan to pre-approve Botox. The Plan denied your request. The Plan says the use of this drug is 
not reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Botox. Our reviewer says that Botox is 
not medically reasonable and necessary for the enrollee. Our physician reviewer found the record indicates that 
the enrollee has a diagnosis of urinary incontinence in the setting of prostatic hypertrophy and urethral stricture. 
The record provided is insufficient to establish that the enrollee has an overactive bladder as the etiology of 
incontinence. Our reviewer found that the FDA has not stated that the requested drug is indicated for the 
enrollee's condition. Our physician reviewer also found that the Medicare approved drug compendia do not 
contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Botox (J0585).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve massage therapy (97124). 
 
You asked the Plan to pre-approve massage therapy. You say that you have pain all over your body. You say 
that you need a hands-on massage. You say that chiropractic service could kill you. You also say that you may 
have to go to urgent care or emergency room because it is getting worse. The Plan denied your request. The 
Plan says massage therapy is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, 
we decided that the Plan does not have to pre-approve massage therapy (97124).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (80299) provided on October 8, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not 
supported. 
 
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, the CPT Code Manual definition of code 80299 is "Quantitation of therapeutic drug, not elsewhere 
specified". 
 
We asked our coder 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 services. Our reviewer says that the use of code 80299 is 
not supported by the records provided. Our reviewer found that the laboratory order is for a custom panel, for 
metaboutlite analysis and validity testing. After reviewing the laboratory report, "quantitation of therapeutic 
drug not elsewhere specified" was documented in the report, as well as no explanation for what testing this 
procedure this code is being reported for. In this case, this procedure cannot be verified. 
 We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (80299) provided on October 8, 2021.