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

 
We decided that the Plan does not have to pay for a wig provided on April 29, 2022. 
 
You asked the Plan to pay for a wig. You say that you have suffered emotional and psychological distress. The 
Plan denied your request. The Plan says the service is excluded from coverage. 
 
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are 
ordered by a physician. The Plan follows these same rules. 
 
In this case, although the wig may be appropriate, it is not considered DME because it does not directly treat a 
medical condition. It does not replace an internal body organ or attached tissue. As such, it is noncovered by 
Medicare. Furthermore, the Plan does not offer a supplemental benefit which would provide coverage for a 
wig. Therefore, we decided that the Plan does not have to pay for a wig provided on April 29, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation of the sacroiliac joint. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says currently, completed studies say that this procedure does not improve outcomes 
compared to standard treatment. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that this procedure is considered experimental and investigational because of the wide variation in 
efficacy reported in the literature. 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve radiofrequency ablation of the sacroiliac joint.
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 would benefit from inpatient rehabilitation 
services due to your medical complexity. The Plan denied your request. The Plan says you do not meet the 
Medicare criteria for admission to an IRF. 
 
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 there are no complex nursing or rehabilitation needs. While you have a need for 
physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 
 
  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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan of the brain 
(78608). 
 
You asked the Plan to pre-approve a PET scan of the brain. The Plan denied your request. The Plan says the 
criteria for coverage are not met. 
 
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 AD and 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 a PET scan of the brain. Our reviewer 
says that the enrollee does not meet the criteria for coverage for a PET scan of the brain. Our physician 
reviewer found the enrollee has had a significant cognitive decline past year. The Mini-Mental State 
Examination (MMSE) is very abnormal at 16/30, and an imaging workup has been done. Our reviewer found 
that there is no mention of possible frontotemporal dementia (FTD) as a differential diagnostic consideration.  
Such a consideration is necessary per NCD guidelines for The Centers for Medicare & Medicaid Services 
(CMS) approval. Our physician reviewer also found that absent such a differential, the enrollee does not fulfill 
CMS guidelines for approval. 
 
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 PET scan of the brain have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a positron emission tomography (PET) scan of the brain (78608).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vertiflex Superion device (22869, 22870). 
 
You asked the Plan to pre-approve Vertiflex device. You say that this treatment is considered safe and 
effective. The Plan denied your request. The Plan says the requested device is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Vertiflex device. Our reviewer says that 
the requested Vertiflex device is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the requested device is considered experimental. Therefore, the reviewer found that Vertiflex 
device 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 Vertiflex device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Vertiflex Superion device (22869, 22870).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of a ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that you are appealing this denial. The Plan denied your 
request. The Plan says a ventilator is not covered by Medicare for this purpose and the enrollee's needs could 
be met by a bilevel positive airway pressure device. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilator products used to provide continuous or 
bilevel positive airway pressure therapy, regardless of the underlying medical condition, are not covered.  
 
We looked at the file and Medicare rules. A ventilator is not covered by Medicare for this purpose. Based on 
this information, we decided that Medicare rules for coverage of ventilator have not been met. Therefore, we 
decided that the Plan does not have to pre-approve use of a ventilator.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (0037U) provided on July 5, 2022. 
 
You asked the Plan to pay for the lab services. You say that this test was medically necessary and was provided 
for a covered indication. 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. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (0037U) provided on July 5, 2022.
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 you want to get started on rehab as soon as possible. 
The Plan denied your request. The Plan says criteria for admission to the IRF setting have not been met. Your 
ongoing skilled therapy and nursing needs can be provided at a lower level of care. 
 
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 that you are medically stable and do not need a physical medicine and rehabilitation physician's close supervision 3 times per week (at a minimum) for the ongoing management of any active or 
acute exacerbations of chronic medical conditions. You have no nursing needs documented. At your current 
functional level, you do not need 3 hours a day for 5 days a week of therapies with multidisciplinary approach 
in an IRF. While you may benefit from physical therapy and occupational therapy, your rehabilitation needs 
can be safely met in an alternate and low intensity setting such as in an 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.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eliquis. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary for the patient's treatment 
of pulmonary hypertension. The Plan denied your request. The Plan says the requested drug is intended for 
patient self-administration. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Eliquis.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve Intracept. You say that this is medically necessary and supported by strong 
science. The Plan denied your request. The Plan says this is considered 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 Intracept. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found documentation is lacking regarding reasonable detailed and evidenced finding supporting of the 
spinal vertebral bodies as being the overwhelming primary generators of the enrollee's chronic persistent pain. 
Documentation does not support actual formal surgical ablation of pre-designated basivertebral nerves as being 
medically necessary at this time. There is no compelling rationale or extenuating circumstance presented to 
support the necessity of this request as an exception to guidelines. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Intracept have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Intracept procedure.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgery services provided to the enrollee on November 29,
2021, and billed under codes 75710, 36245, 36247, 35372 and 75736.
You asked the Plan to pay for any of this claim as billed. You say that these services should be covered by the
Plan. The Plan denied your request. The Plan says the records provided do not support the services billed.
Maximus partially overturned the Plans denial for a lack of medical records in the file. The plan requested a
reopen and provided additional medical records.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. Code 75710 is a column II code to column I code 35371. Code 75710 has not been
billed with an appropriate modifier to bypass the edit. For codes 36245, 36247, 35372 and 75736, the Plan has
provided documentation which confirms the medical records do not support the services billed.
The operative report provided do not include the documentation required based on Medicare guidelines to show
this claim was billed appropriately. Therefore, we decided that the Plan does not have to pay for surgery
services provided to the enrollee on November 29, 2021, and billed under codes 75710, 36245, 36247, 35372
and 75736.
Appeal type: Imaging
Decision: Unfavorable

We decided the Plan does not have to pay a second claim for imaging services provided September 24, 2021,
billed under code 74018.
You asked the Plan to pay this claim. You say that this claim should be paid. The Plan denied your request. The
Plan says this claim is a duplicate of a previously paid claim and was correctly denied. Maximus overturned the
Plans denial for medical necessity. The Plan requested a reopen and stated this was not a medical necessity
issue but a duplicate payment issue.
The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that claims or claim lines
that have been determined to be exact duplicates of another claim or claim line are denied. The Plan provided
documentation to show these services were billed by the same providers and paid to the same providers on
September 24, 2021, and November 10, 2021. Comparison of the two claims shows these are exact duplicates.
There is no evidence presented to support that the billed services were provided twice on the same date. Based
on this information, we decided that the Medicare rules for this claim have not been met. Therefore, we decided
that the Plan does not have to pay imaging services provided to the enrollee on September 24, 2021, billed
under code 74018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral-periapical first radiographic image (D0220),
intraoral-periapical each additional radiographic image (D0230), the 2D oral/facial photographic image
(D0350), and the comprehensive oral evaluation (D0150) provided on December 16, 2021.
You asked the Plan to pay for the dental services. You say that you are requesting a reconsideration of the
Plan's denial for payment. The Plan denied your request. The Plan says your benefit for the comprehensive oral
evaluation 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 Plan's 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
comprehensive oral evaluation was exhausted on date of service June 12, 2019.
The intra-oral periapical x-rays and 2D oral/facial photographic images are not among those covered under this
benefit. Therefore, we decided that the Plan does not have to pay for the intraoral-periapical first radiographic
image (D0220), intraoral-periapical each additional radiographic image (D0230), the 2D oral/facial
photographic image (D0350), and the comprehensive oral evaluation (D0150) provided on December 16, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgery services (27357) provided on December 29, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says while a portion of this claim was paid, the records provided do not support the billing of
27357. In addition, code 27357-51-LT would be considered inclusive to procedure code 27447-LT (another
billed code). The requested code 27357-51-LT cannot be verified as performed based on the records provided.
Maximus overturned the Plans denial for insufficient information. The Plan requested a reopen and provided
additional documentation. The Plan confirms the operative report does not support the services billed.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that the provider,
supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to
determine whether payment is due and the amount of payment. Based on the medical records provided, we
decided that there is insufficient information in the record to determine if Medicare rules for coverage of code
27357-51-LT were met. Therefore, we decided that the Plan does not have to pay for surgery services (27357)
provided to the enrollee on December 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for an expandable controller and accessories
(E2377, E2313, E2311).
You asked the Plan to provide coverage for expandable controller and accessories (E2377, E2313, E2311).
You say that at the time of the appeal, the expandable controller, and accessories (E2377, E2313, E2311) were
medically necessary. The Plan denied your request. The Plan says the requested items are not covered by
Medicare and exceed your equipment needs. Maximus overturned the Plans denial. The Plan requested a
reopen and stated that Maximus did not apply the correct criteria.
The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that for equipment to be
covered, it must primarily serve a medical purpose. The rules state specific accessories are covered based on
physical need to accommodate use of a specific power wheelchair in the home. The denied accessories are only
approved when there is a medical need to control three or more power options though the joystick. Only two
power options are requested and those two were approved. The medical records were reviewed and do not
show you have a medical need to control the power options through the joystick. The power options can be
controlled using their own switches and can be configured to accommodate size needs. Medicare coverage
criteria for the requested accessories are not met. Therefore, we decided that the Plan does not have to provide
coverage for an expandable controller and accessories (E2377, E2313, E2311).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a Group 3 power wheelchair (K0861) and
multiple accessories (E2311, E1007, E1012, E2361, E1028, E0955, E2620, E2622, E2313, E2377 and E2620).
You asked the Plan to provide coverage for a specific Group 3 Power wheelchair. You say that at the time of
the appeal, the requested power wheelchair and accessories were medically necessary. The Plan denied your
request. The Plan says Medicare coverage criteria for the specific power wheelchair and accessories requested
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 is correct in this case. The Plan must follow Medicare rules. Medicare has specific coverage criteria
for Group 3 Power wheelchairs and related accessories. The medial records submitted do not sufficiently
support the need for the specific Group 3 chair requested nor is the diagnosis one that qualifies for the
requested power wheelchair. In addition, the Plan offered an alternative power wheelchair that would meet
your needs in the home. Therefore, we decided that the Plan does not have to provide coverage for a Group 3
power wheelchair (K0861) and multiple accessories (E2311, E1007, E1012, E2361, E1028, E0955, E2620,
E2622, E2313, E2377 and E2620).
Appeal type: Testing
Decision: Unfavorable

We decided the Plan does not have to provide coverage for Bioimpedance spectroscopy (BIS) for the enrollee.
You asked the Plan to provide coverage for Bioimpedance spectroscopy (BIS). You say that at the time of the
appeal this treatment was medically necessary. The Plan denied your request. The Plan says this treatment is
not covered by Medicare. Maximus overturned the Plans denial. The Plan requested a reopen and stated that
Maximus did not apply the correct criteria.
The Plan is correct in this case. Our Medical Director states that NCCN Guidelines Version 1.2022
Survivorship: Lymphedema does not recommend Bioimpedance spectroscopy (BIS) in the management of or
surveillance for lymphedema. The evidence in the medical literature and the clinical documentation in this case
are insufficient to support that bioimpedance spectroscopy is medically reasonable and necessary in this case.
Therefore, we decided that the Plan does not have to provide coverage for Bioimpedance spectroscopy (BIS)
for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a multi-positional patient transfer system. 
 
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no information sent as to why this lift is needed to perform a supine transfer. 
 
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 system. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the medical records do not show a requirement for the enrollee to have a supine position during 
transfer. 
 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 system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a multi-positional patient transfer system.