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

 
We decided that the Plan does not have to pay for the nursing facility care provided on June 1, 2023, by an 
OON provider.  
 
You asked the Plan to pay for the nursing facility care. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says this service is not covered when received by an 
OON provider. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has a POS option to use either network providers or out-of-network providers for certain 
covered services. The Plan contract also says that out-of-network skilled nursing facility care is not covered. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we 
decided that the Plan does not have to pay for the nursing facility care provided on June 1, 2023, by an OON 
provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an alignable system described (L5920) and a multi-axial
rotational unit (L5986).

You asked the Plan to pre-approve an alignable system described and a multi-axial rotational unit. You say that
you disagree with the denial. The Plan denied your request. The Plan says that the services are not medically
necessary.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for an alignable
system described and a multi-axial rotational unit. Our Medical Director states that the clinical documentation
does not support that a multi-axial rotational unit (L5986) was medically reasonable and necessary for the
enrollee in this case. The requested multi-axial rotation unit requested under code L5986 does not describe an
entire foot. The services cannot be approved with this code. Our Medical Director found that your condition
does not meet criteria for coverage of an alignable system described and a multi-axial rotational unit.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of an alignable system described and a multi-axial rotational unit have not been
met. Therefore, we decided that the Plan does not have to pre-approve an alignable system described (L5920)
and a multi-axial rotational unit (L5986).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a complete upper denture (D5110), a partial
lower denture (D5212), and the removal of torus mandibularis (D7473x2).

You asked the Plan to provide coverage for a these dental services. The Plan denied your request. The Plan
says that your benefit for the requested dental services had already been exhausted. Maximus overturned the
Plans denial for a lack of claim information to show this benefit was exhausted. The Plan requested a reopen
and provided the required claim information.

The Plan is correct in this case. 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 more than Medicare coverage, the claim records show this benefit was
not available at the time of the appeal request. Therefore, we decided that the Plan does not have to provide
coverage for a complete upper denture (D5110), the partial lower denture (D5212), and the removal of torus
mandibularis (D7473x2).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox (onabotulinumtoxinA) (J0585) for the enrollee.

You asked the Plan to pre-approve Botox. The Plan denied your request. The Plan says that Raynaud's
syndrome is not listed as a labeled or off label coverage indication.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for Botox. Our
Medical Director states that the enrollee has arthritis and severe Raynaud's phenomenon. The documentation
does not support that the enrollee in this case had a covered indication for Botox. Our Medical Director found
that the enrollee's condition does not meet criteria for coverage of Botox.

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 (onabotulinumtoxinA) (J0585) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Sprint peripheral nerve stimulator (PNS) (64555). 
 
You asked the Plan to pre-approve the Sprint PNS. You say that this is medically necessary. The Plan denied 
your request. The Plan says this 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 the Sprint PNS. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Sprint PNS device is experimental for neck pain. More research is needed. 
 
   
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 Sprint PNS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Sprint peripheral nerve stimulator (PNS) (64555).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neuropsychological testing (96132, 96133). 
 
You asked the Plan to pre-approve neuropsychological testing. You say that this is medically necessary. The 
Plan denied your request. The Plan says The records indicate a history of back pain, but they do not indicate the 
reason for neuropsychological testing. The records do not indicate the nature or purpose of neuropsychological 
testing or how it would impact 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 neuropsychological testing. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found you do not meet the criteria for neuropsychological testing as it is unclear 
as to why this testing was ordered and is therefore not considered to be medically necessary or reasonable.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of neuropsychological testing have not been met. Therefore, we decided that the 
Plan does not have to pre-approve neuropsychological testing (96132, 96133).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you need transportation 
for your medical appointments. The Plan denied your request. The Plan says you have utilized the maximum 
number of transportation trips allowed per year. 
 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 a maximum of 10 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen and 
pelvis (74177). 
 
You asked the Plan to pre-approve a CT scan of the abdomen and pelvis. You say that this is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet do not meet medical 
necessity. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 CT scan of the abdomen and pelvis. 
Our reviewer says that the enrollee does not meet criteria for coverage. Our physician reviewer found the 
requested CT 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 a CT scan of the abdomen and pelvis have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen and pelvis 
(74177).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from October 23, 2023, 
forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from October 23, 2023, forward. You say that the 
services at issue were medically necessary. The Plan denied your request. The Plan says the services at issue 
were not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care from October 
23, 2023, forward. Our reviewer says that the enrollee does not meet the criteria for treatment in an acute 
inpatient mental health treatment beyond the date in question of October 23, 2023, forward. Our physician 
reviewer found the enrollee did not require inpatient mental health treatment beyond October 23, 2023, as she 
was not a danger to herself or others and did not have any delusions, auditory or visual hallucinations. It did not 
appear that active treatment was taking place beyond the date in question. It did not appear that the services for 
the dates in question were reasonably expected or medically necessary to improve the enrollees condition or 
for the purpose of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from October 23, 2023, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from October 23, 
2023, forward.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs billed for April 26, 2023, to May 
4, 2023. 
 
You asked the Plan to pay for the medication. You say that you did not self-administer any drugs. The Plan 
denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
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 pay for the self-administered drugs 
billed for April 26, 2023, to May 4, 2023.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty (22513). 
 
You asked the Plan to pre-approve kyphoplasty. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that percutaneous vertebroplasty and percutaneous 
vertebral augmentation (PVA or Kyphoplasty) procedures will be considered medically reasonable and 
necessary for certain indications. 
 
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 kyphoplasty. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found detailed documentation is not evident 
regarding an L1 compression fracture corroborated by advanced diagnostic imaging. X-rays are noted to show 
L1 compression deformity with estimated 60-80% loss of overall vertebral body height. However, the date of 
these x-rays was not noted, and the formal report was not provided. Moreover, there is magnetic resonance 
imaging (MRI) corroboration of retropulsion of the T12 compression fracture, which is noted to be chronic. 
Therefore, you do not meet the coverage criteria detailed in the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve kyphoplasty (22513).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99204) and the electric stimulation therapy  
(97014 x 3) provided from June 7, 2023, through June 15, 2023. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the office visit (99204) and electric stimulation therapy (97014 x 3), 
provided from June 7, 2023, through June 15, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an osteogenesis stimulator, low intensity ultrasound, 
non-invasive (E0760). 
 
You asked the Plan to pre-approve an osteogenesis stimulator. You say that the device is medically necessary. 
The Plan denied your request. The Plan says you do not meet criteria for approval of the requested device. 
 
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 an osteogenesis stimulator. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the medical documentation supports that you are suffering with a slowly 
healing fifth metatarsal fracture right side. Medicare guidelines advise that bone stimulators are recommended 
for treatment of a nonunion fracture. Criteria that must be met include a minimum of two sets of radiographs 
obtained prior to starting treatment with the osteogenesis stimulator, separated by a minimum of 90 days. Each 
radiograph set must include multiple views of the fracture site accompanied by a written interpretation by a 
treating practitioner stating that there has been no clinically significant evidence of fracture healing between the 
two sets of radiographs. The medical documentation does not support that the above-mentioned criteria have 
been met with regards to two sets of x-rays separated by 90 days which demonstrated no healing of the 
fracture. Therefore, the enrollee does not meet the coverage criteria for an osteogenesis bone stimulator it 
cannot be considered 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 an osteogenesis stimulator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an osteogenesis stimulator, low intensity ultrasound, non-invasive (E0760).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve posterior non-segmental instrumentation (22840), and 
arthrodesis, posterior or posterolateral technique, single interspace; lumbar (22612). 
 
You asked the Plan to pre-approve posterior non-segmental instrumentation, and arthrodesis, posterior or 
posterolateral technique, single interspace; lumbar. You say that this is medically necessary. The Plan denied 
your request. The Plan says the Medicare criteria for reasonable and necessary are not met because use of this 
device as a stand-alone procedure has not been shown to be safe and effective in long term studies. 
 
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 posterior non-segmental 
instrumentation, and arthrodesis, posterior or posterolateral technique, single interspace; lumbar. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no spinal instability fracture or lesion. The imaging shows degenerative 
changes with stenosis. Fusion and instrumentation is not medically needed.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of posterior non-segmental instrumentation, and arthrodesis, posterior or 
posterolateral technique, single interspace; lumbar have not been met. Therefore, we decided that the Plan does 
not have to pre-approve posterior non-segmental instrumentation (22840), and arthrodesis, posterior or 
posterolateral technique, single interspace; lumbar (22612).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99233) provided on May 10, 2023 to 
May 13, 2023. 
 
You asked the Plan to pay for the physician services. You say that this service was 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 99233 is not supported in the medical record. Specifically, the signed records do not 
include the date of service on the physician notes, and the records provided are not signed by the practitioner. 
Based on this information, we decided that Medicare rules for coverage of the physician services have not been 
met. Therefore, we decided that the Plan does not have to pay for physician services (99233) provided on May 
10, 2023 to May 13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter (K0800). 
 
You asked the Plan to pre-approve a power scooter. You say that the item is medically necessary. The Plan 
denied your request. The Plan says the enrollee is able to maneuver with a manual wheelchair. 
 
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.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a power scooter. Our reviewer says that 
the enrollee does not need this item. Our physician reviewer found there is a lack of clinical documentation indicating the enrollees level of mobility and physical examination findings, specifically with regards to motor 
strength in the upper and lower extremities. He is noted to be at risk for falling and may not be able to use a 
cane or walker. However, he can use a manual wheelchair for mobility and accomplishing his daily activities. 
There is no indication that the patient cannot propel a manual wheelchair. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a power scooter have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power scooter (K0800).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the chest. 
 
You asked the Plan to pre-approve a CT scan of the chest. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 CT scan of the chest. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found the record indicates that the 
enrollee has two pulmonary nodules that have been stable in size since 2016. The provided records do not 
indicate the medical necessity or reasonableness, as defined by Medicare rules, of the requested service. 
 
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 CT scan of the chest have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a computed tomography (CT) scan of the chest.