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

We decided that the Plan does not have to provide coverage for a Group 2 powered pressure reducing mattress.

You asked the Plan to provide coverage for a Group 2 powered pressure reducing mattress. The Plan denied
your request. The Plan says the Medicare coverage criteria were not met. Maximus partially overturned the
Plans denial for the Sequential Compression Device.

The Plan requested a reopen and noted that they had approved the Sequential Compression Device prior to our
original decision and only the air mattress was denied.

The Plan must follow Medicare rules. Medicare has specific coverage criteria for this type of mattress.
Medicare only replaces durable medical equipment every 5 years. 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 group 2 powered pressure reducing mattress. Our reviewer says you are reported to
have reduced bed mobility due to weakness from multiple sclerosis. You currently have a Med Aire alternating
pressure and low air loss bariatric mattress that is in good condition that is 1-2 years of age. You already have a
powered pressure reducing air mattress that is functional and does not need replacement. The records do not
show you have pressure ulcers. Medicare coverage criteria are not met.

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 Group 2 powered pressure reducing mattress have not been met. In addition,
your current equipment which is found to meet your needs is less than 5 years old. Therefore, we decided that
the Plan does not have to provide coverage for a group 2 powered pressure reducing mattress and a sequential
compression.device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for over-the-counter (OTC) COVID-19 test kits provided on 
July 12, 2023. 
 You asked the Plan to pay for over-the-counter (OTC) COVID-19 test kits. You say that you would like a 
prompt review of this appeal and approval of this approved service. The Plan denied your request. The Plan 
says over-the-counter (OTC) COVID-19 tests are not covered by Medicare after May 11, 2023. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and over-the-
counter COVID-19 test kits is an OTC item. Although the Plan offers coverage for OTC items, over-the-
counter COVID-19 test kits are excluded from this benefit. Therefore, we decided that the Plan does not have 
to pay for over-the-counter (OTC) COVID-19 test kits provided on July 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatment provided by a 
chiropractor on July 17, 2023, by an OON provider.  
 
You asked the Plan to pay for the chiropractic manipulative treatment provided by a chiropractor. You say that 
you are appealing the claim payment denial. The Plan denied your request. The Plan says the services are not 
authorized because the provider is out-of-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the chiropractic manipulative treatment provided 
by a chiropractor on July 17, 2023, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Purewick urine collection system. 
 
You asked the Plan to pay for the Purewick urine collection system. You say that you need this item. The Plan 
denied your request. The Plan says the providers website states they do not accept Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the Purewick urine collection system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 1 heavy duty power operated vehicle (POV) 
with a patient weight capacity 301 to 450 pounds (K0801). 
 
You asked the Plan to pre-approve a group 1 heavy duty POV. You say that you do not fit in the regular scooter 
due to your height. The Plan denied your request. The Plan says this request does not meet the Medicare or 
health plan coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that a PWC is covered if the beneficiarys weight is 
less than or equal to the weight capacity of the power wheelchair that is provided and greater than or equal to 
95% of the weight capacity of the next lower weight class PWC. 
 
 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a group 1 heavy duty POV have not been met. Specifically, the provided records show that your 
most recent documented weight is below the required weight limit of 301 to 450 pounds for a group 1 heavy 
duty POV (K0801). Therefore, we decided that the Plan does not have to pre-approve a group 1 heavy duty 
power operated vehicle (POV) with a patient weight capacity 301 to 450 pounds (K0801).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for over-the-counter COVID-19 test kits provided on July 27, 
2023. 
 
You asked the Plan to pay for over-the-counter COVID-19 test kits. You say that you would like a prompt 
review of this appeal and approval of this approved service. The Plan denied your request. The Plan says over-
the-counter (OTC) COVID-19 tests are not covered by Medicare after May 11, 2023. 
 The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and over-the-
counter COVID-19 test kits is an OTC item. The Plan does not offer coverage for OTC items, which includes 
COVID-19 test kits. Therefore, we decided that the Plan does not have to pay for over-the-counter COVID-19 
test kits provided on July 27, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the heart.  
 
You asked the Plan to pre-approve the CT scan. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the imaging being requested is not a covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that all services that are medically necessary and 
meet accepted standards will be covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
computed tomography (CT) scan of the heart.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for immunization services provided on April 26, 2023. 
 
You asked the Plan to pay for immunization services. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says that you can pay for the vaccine and administration 
for your vaccines in your doctor's office, then request a refund for the costs through your Part D Pharmacy 
coverage. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide immunization 
services. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to immunization 
services. Therefore, we decided that the Plan does not have to pay for immunization services provided on April 
26, 2023.  
 
Benefits for immunization services 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction (D7210) provided on July 10, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
 
  The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for an extraction (D7210) provided 
on July 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99309 and G8427 billed for date of service 
March 3, 2023. 
 
You asked the Plan to pay for the billed service. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the modifier is not payable by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. We find that CPT codes 99309 and G8427 are not supported in the medical record. The codes at issue were 
billed with modifier -HE which is not among those suitable for payment. Based on this information, we decided 
that Medicare rules for coverage of the billed service have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure codes 99309 and G8427 billed for date of service March 3, 2023.
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 admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF 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 complexity of your nursing, medical and rehabilitation needs do not require an 
acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, at an 
intensive rehabilitation therapy program. You continue to have a need for skilled therapy with ongoing safety 
concerns and a potential for functional improvement however, the documentation doesnt support that you 
would meet criteria for admission to an acute inpatient rehabilitation facility. There is no indication that you 
would require skilled rehabilitation in an IRF, participating in rehabilitation services 15 hours a week, under 
the supervision of a physician with at least 3 visits weekly to regain or maintain functional status. You can 
receive further services at a lower 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hip orthosis (L1686), and accessory (L2624), provided on 
April 25, 2023. 
 
You asked the Plan to pay for the hip orthosis and accessory . You say that the items should be covered. The 
Plan denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. There is no indication these items were needed or ordered in the clinical documentation submitted. 
The record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for the hip orthosis (L1686), and accessory (L2624), 
provided on April 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan has to pay for root extraction (D7250), extraction (D7140) and extraction (D7210).
We decided that the Plan does not have to pay for nitrous oxide (D9230).

You asked the Plan to pay for dental services provided on February 2, 2023. The Plan says that these dental
services were not covered. Maximus upheld the Plans original denial. You requested an Administrative Law
Judge (ALJ) hearing. The ALJ remanded the case back to Maximus for further review. Maximus upheld the
case remanded by the ALJ, however that decision required further explanation, so the case was reopened a
second time.

Our Project Director reviewed the case file. Our Project Director states that the Plan provided an accepted
rationale for the denial of nitrous oxide (D9230) as this service is clearly not covered under the dental benefit.
However, for the remaining dental codes, the Plan did not provide a good rationale for their denial. The
reference to denture realignment in the case file does not apply here. Absent any other argument raised by the
Plan and given that these are covered services under the Plan benefit, we are overturning codes D7250, D7140,
and D7210, for insufficient information in the case file to support the Plans denial. Therefore, we decided that
the Plan does not have to pay for root extraction (D7250), extraction (D7140) and extraction (D7210).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a Flex-walk system or equal (L5981), and a
multi-axial ankle with swing phase active dorsiflexion (L5968).

You asked the Plan to provide coverage for a Flex-walk system or equal (L5981), and a multi-axial ankle with
swing phase active dorsiflexion (L5968). 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 noted 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 Flex-walk
system or equal (L5981), and a multi-axial ankle with swing phase active dorsiflexion (L5968). The Maximus
Physician Reviewer determined that the enrollee needed the requested items. The reviewer found that the
enrollee is a K3 ambulator and entitled to this class of componentry. The Plan argued that the medical record
does not corroborate that the enrollee is a K3 ambulator. The medical records show the enrollee is a 54-yearold
man with a medical history that includes diabetes, hypertension, peripheral vascular disease, a left belowknee
amputation, and a right forefoot amputation. The progress note dated March 30,2023 documents that the
enrollee is in need of a left replacement prosthesis. It is documented that the enrollee has generalized debility
and is wheelchair dependent for mobility.

The available clinical documentation is insufficient to demonstrate that the enrollee in this case is a K3
ambulator, and that the requested Flex-walk system or equal (L5981), and Multi-axial ankle with swing phase
active dorsiflexion (L5968) are/were medically reasonable and necessary for the enrollee in this case.

We looked at this physician's review, the file, and the Medicare rules. Based on this information, we decided
that Medicare rules for coverage the requested equipment were not met. Therefore, we decided that the Plan
does not have to provide coverage for a Flex-walk system or equal (L5981), and a multi-axial ankle with swing
phase active dorsiflexion (L5968).
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for the home health care billed for dates of service May 16, 2023, to May 
18, 2023. 
 
You asked the Plan to pay for the billed services. You say that there is nothing incorrect on the claim. The Plan 
denied your request. The Plan says that no qualifying skilled service was billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code.  
 We looked at the file and the rules. In this case, the claim at issue was billed with qualifying skilled services 
and a payable revenue code. Based on this information, we decided that Medicare rules for coverage of the 
billed services have been met. Therefore, we decided that the Plan has to pay for the home health care billed for 
dates of service May 16, 2023, to May 18, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of an implanted loop recorder (ILR). 
 You asked the Plan to pre-approve the requested ILR procedure. You say that this is medically necessary. The 
Plan denied your request. The Plan says the enrollee has not had a cryptogenic stroke, has no history of 
syncope, and does not need an ILR for diagnosis of palpitations. An ILR is not medically necessary to monitor 
heart arrhythmias in the absence of a stroke or syncope. 
 
The Plan must follow Medicare rules. Medicare rules say ILR placement may be considered medically 
necessary when it is needed to evaluate syncope that is thought to be cardiac-related but occurs too infrequently 
to be detected by traditional external monitors.  
 
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 requested ILR procedure. Our 
reviewer says that the requested ILR procedure is not medically reasonable and necessary based on NCD 
criteria. Our physician reviewer found while the enrollee has a history of atrial fibrillation, there is no 
documentation provided to suggest a history of unexplained syncope, cryptogenic stroke or any other apparent 
indication for an ILR. 
 
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 requested ILR procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve placement of an implanted loop recorder (ILR).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the services are medically necessary for you to 
continue receiving the services needed. The Plan denied your request. The Plan says continuation of SNF is not 
medically necessary and does not meet Medicare guidelines. 
 
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 you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing or skilled therapy on an inpatient basis in a skilled nursing facility (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 skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block (64454). 
 
You asked the Plan to pre-approve the nerve block. You say that this is medically necessary for the enrollee. 
The Plan denied your request. The Plan says this is experimental and therefore is not covered. 
 
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 nerve block. Our reviewer says that 
the requested genicular nerve block is not considered medically reasonable and necessary in this case. Our 
physician reviewer found this is considered experimental therapy. It is the subject of ongoing clinical trials. 
Therefore, the reviewer found that the requested genicular nerve block is 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 nerve block have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a genicular nerve block (64454).