Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 4 home health occupational therapy visits.  

You asked the Plan to pre-approve 4 home health occupational therapy visits. You say that you would like to 
request reconsideration of the denied home health occupational therapy visits and that the services requested 
are medically necessary. The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health occupational therapy 
visits. Our reviewer says that the services are not medically reasonable and necessary. Our physician reviewer 
found the enrollee's progress has plateaued, and this does not require the ongoing services of a skilled 
occupational therapist. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health occupational therapy visits have not been met. Therefore, we 
decided that the Plan does not have to pre-approve 4 home health occupational therapy visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for 
admission to an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
  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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the patient appears to be improving with current treatment and should only require 
short-term additional acute care services that can safely be provided at the current facility until more 
appropriate for transfer to a lower level of care. The patient does not require services at the LTACH that are not 
already available at the current facility.  
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87798, 87481, 87653, and 87641 billed for 
date of service August 17, 2023. 
 
You asked the Plan to pay for procedure codes 87798, 87481, 87653, and 87641. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says payment for codes 87798, 87481, 87653, 
and 87641 is bundled into payment for code 87801. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also state that providers may bill 
services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service. 
 
In this case, we have confirmed that code 87798, 87481, 87653, and 87641 are column II codes to column I 
code 87801. While these codes were billed with modifier -59, the medical records provided do not show that 
the service billed with the -59 modifier are a distinct procedural service. 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 codes 87798, 87481, 87653, and 87641 billed for date of service August 17, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the abdominoplasty. 
 
You asked the Plan to pre-approve the abdominoplasty. You say that the abdominoplasty is medically 
necessary. The Plan denied your request. The Plan says the abdominoplasty 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 abdominoplasty. Our reviewer says 
that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the record indicates that you have lipodystrophy secondary to medications. The record provided 
does not document the presence of chronic intertrigo refractory to at least three months of medical therapy or 
functional impairment. The elements of the coverage criteria are not satisfied. The requested service is not 
recommended. 
 
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 abdominoplasty have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the abdominoplasty.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 96 units of procedure code 00830 provided August 28, 2023. 
 
You asked the Plan to pay for the services. You say that the number of units for procedure code 00830 was 
billed correctly. The Plan denied your request. The Plan says the medical records do not support the number of 
units 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. 
 
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 found the submitted medical records indicate anesthesia for a hernia repair in the lower abdomen as performed; however, the records do not 
support the number of units billed. The submitted anesthesiology bill for CPT 00830 of 96 units is NOT 
supported in this case. [Corrected anesthesiology bill = 8.9 units.] 
 
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 96 units of procedure code 00830 provided August 28, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87640, 87491, and 87798 billed for date of 
service August 11, 2023. 
 
You asked the Plan to pay for procedure codes 87640, 87491, and 87798. You say that you would like the Plan 
to reconsider their denial of payment. The Plan denied your request. The Plan says payment for code 87640 is 
bundled into payment for code 87641. Additionally, the laboratory order does not include services described by 
procedure codes 87491 and 87798. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Medicare rules also 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. 
 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 87640 
is a column II code to column I code 87641. This claim has not been billed with an appropriate modifier to 
bypass the edit as modifier 59 is not supported. Additionally, the laboratory order does not include services 
described by procedure codes 87491 and 87798. 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 codes 87640, 87491, and 
87798 billed for date of service August 11, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Chemotherapy provided on August 18, 
2022. 
 
You asked the Plan to waive the coinsurance for Chemotherapy. You say that you had reached your out-of-
pocket cost for the year. 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 20% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for Chemotherapy. This item/service falls within the Medicare 
Part B prescription drugs 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. You have been asked to pay a total of $1,171.63 for chemotherapy. Therefore, we decided 
that the Plan does not have to waive the coinsurance for Chemotherapy provided on August 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 85045 provided on September 15, 2023. 
 
You asked the Plan to pay for procedure code 85045. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
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. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of procedure code 85045 have been met. 
In this case, the laboratory order provided does not include a request for procedure code 85045. Therefore, we 
decided that the Plan does not have to pay for procedure code 85045 provided on September 15, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311), a harness (E2313) 
and an expandable controller (E2377). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that the requested accessories are 
medically necessary for the enrollee's condition. The Plan denied your request. The Plan says an electronic 
connection, an expandable controller and an expandable controller harness cannot be covered as it is not 
medically necessary to control the three approved power options through the joystick (drive interface). 
 
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 wheelchair accessories. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has paraplegia. No evidence of upper extremity paralysis or impairment. 
No upper extremity functional assessment is provided. Per Social Security Administration (SSA) 1862 (a)1(A), 
the requested accessories are not medically necessary as the enrollee has adequate strength to manage standard 
power drives. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of wheelchair accessories have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an electronic connection (E2311), a harness (E2313) and an expandable controller 
(E2377).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for an Ottobock Kenevo MPK and Ottobock
Maverick Comfort prosthetic equipment for the enrollee.

You asked the Plan to provide coverage for an this prosthetic equipment. You say that at the time of the appeal,
this prosthetic equipment was medically necessary. The Plan denied your request. The Plan says the records
provided do not support the required Medicare criteria were met. Maximus overturned the Plans denial. The
Plan requested a reopen and stated that Maximus did not apply the correct criteria. The Plan noted that the first
issue is with the codes requested as this equipment, codes L5848, L5845, L5828, and L5856 are considered as
one unit and each code cannot be requested separately. The Plan states the physician documents that the
enrollee has K3 potential, but there is no documentation as to why a microprocessor knee is medically
necessary for the member. The medical records do not show why a mechanical knee cannot be used for the
enrollee's prosthesis, especially given the weight of a microprocessor knee and the enrollee's co-morbidities.
The medical records do not give any medical reason why a mechanical K3 knee will not meet the enrollee's
need. The Plan also notes a microprocessor knee weighs more than a mechanical knee. A microprocessor knee
is more prone to damage and corrosion, especially when exposed to water. A microprocessor knee requires
more maintenance.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that for Medicare to
consider coverage and payment for any item or service, the information submitted by the supplier or provider
must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare
coverage criteria have been met. Medicare has specific coverage criteria for this type of equipment. We looked
at the file and Medicare rules. Based on this information, we decided that there is insufficient information in
the medical records to show the Medicare rules for coverage of this prosthetic equipment were met. Therefore,
we decided that the Plan does not have to provide coverage for an Ottobock Kenevo MPK and Ottobock
Maverick Comfort prosthetic equipment for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the VIA Disc NP procedure (0628T and 0627T).

You asked the Plan to pre-approve the services. You say that this procedure is necessary due to the failure of conservative treatments to address pain and restore function. The Plan denied your request. The Plan says the request 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 services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this therapy is considered experimental/ investigational. Therefore, the request is deemed not medically reasonable and 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 the VIA Disc NP procedure (0628T and 0627T).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve high dose rate electronic brachytherapy. 
 
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your 
request. The Plan says it cannot be said that this is reasonable and necessary at this time. 
 
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 therapy. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there are insufficient long-term efficacy and safety data to support the routine use of electronic 
surface brachytherapy [for treatment of basal cell skin cancer]. As the requested electronic brachytherapy 
(0394T) does not meet Medicare coverage criteria, the requested simulations (77280 and 77290) are not 
covered.  

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 therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve high dose rate electronic brachytherapy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for permanent implantation of an electrical nerve
stimulator for the enrollee.

You asked the Plan to provide coverage for this device. The Plan denied your request. The Plan says the
Medicare coverage criteria are not met. Maximus overturned the Plans denial stating a stimulator trial would be
appropriate. The Plan requested a reopen and stated that Maximus did not apply the NCD criteria as this was
for permanent implantation, not a trial.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare has specific coverage criteria
for the permanent implantation of this device. Medicare rules say that for Medicare to consider coverage and
payment for any item or service, the information submitted by the supplier or provider must corroborate the
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have
been met. Based on the medical records provided, the medical records submitted do not show the enrollee met
all of the required criteria for approval for permanent implantation of this device. Therefore, we decided that
the Plan does not have to provide coverage for permanent implantation of an electrical nerve stimulator for the
enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for ultrasound, transvaginal and ultrasound, pelvic provided to
the enrollee on March 31, 2023.

You asked the Plan to pay for these services. The Plan denied your request. The Plan says the records provided
do not support the services billed. Maximus overturned the Plans denial for insufficient information in the case
file. The Plan requested a reopen and provided additional information. The Plan noted that the provider listed
the primary diagnosis for these procedures as Z12.73 defined as an encounter for screening for malignant
neoplasm of ovary.

The Plan notes there was no documentation of pelvic pain, abnormal vaginal bleeding, abnormal physical
examination findings, or other signs or symptom supporting the medical necessity for these tests. The Plan
notes the United States Preventive Services Task Force recommends against screening for ovarian cancer in
asymptomatic women.

The Plan is correct in this case. The Plan follows Medicare rules. The rules explicitly say that screening tests
are not covered. The records provided do not show this ultrasound was ordered for any specific symptoms or
indications of a medical issues which would require this type of imaging. Medicare does not cover this test for
screening purposes. Therefore, we decided that the Plan does not have to pay for ultrasound, transvaginal and
ultrasound, pelvic provided to the enrollee on March 31, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311), a harness (E2313) 
and an expandable controller (E2377). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that the requested accessories are 
medically necessary for the enrollee's condition. The Plan denied your request. The Plan says although there 
are three requested power options, there is not a medical need to control these power options through the 
joystick. 
 
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 wheelchair accessories. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has Parkinson's disease and hemiplegia. The enrollee has 3/5 strength at 
minimum in upper right extremity. Per Social Security Administration (SSA) 1862 (a)1(A), the requested 
accessories are not medically necessary as the enrollee has adequate strength to manage standard power drives. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of wheelchair accessories have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an electronic connection (E2311), a harness (E2313) and an expandable controller 
(E2377).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF)
admission and services for the enrollee.

You asked the Plan to provide coverage for IRF care. You say that at the time of the appeal, IRF admission was
medically necessary. The Plan denied your request. The Plan says the 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. The Plan noted that the medical records show the enrollee was admitted to the hospital with a
surgical complication of recent left mastectomy. The enrollee was medically stable and high functioning
requiring only contact-guard assist for mobility. The enrollee was documented to have normal upper extremity
strength and was ambulating 175 feet with a platform walker.

The Plan notes the enrollee did not meet the criteria for admission to an IRF level of care.

The Plan is correct in this case. 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. Based
on the medical records provided, the enrollee did not require daily skilled nursing or daily skilled therapy
services at an IRF level of care. Therefore, we decided that the Plan does not have to provide coverage for
acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.