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

 
We decided that the Plan does not have to pay for the lab services provided on December 29, 2022. 
 
You asked the Plan to pay for the lab services. You say that a unique identifier was not required. 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. The claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services provided on December 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-covered chiropractic services represented by 
procedure code 97035 provided from January 9, 2023, to February 6, 2023. 
 
You asked the Plan to pay for procedure code 97035. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says procedure code 97035 is not payable when 
billed by a chiropractor. 
 
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 represented by procedure code 97035 are not manual manipulation 
of the spine. Therefore, we decided that the Plan does not have to pay for the non-covered chiropractic services 
represented by procedure code 97035 provided from January 9, 2023, to February 6, 2023.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care for the enrollee.
You asked the Plan to pre-approve SNF care. You say that at the time of the appeal, SNF care was medically
necessary. The Plan denied your request. The Plan says Medicare coverage criteria were not met. Maximus
overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct
criteria.
The Plan is correct in this case. 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.
Based on the medical records provided, the enrollee care was custodial in nature, with no expectation of further
improvement of baseline. Medicare coverage criteria were not met. Therefore, we decided that the Plan does
not have to pre-approve skilled nursing facility (SNF) care for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have provide coverage for these prosthetic components.
You asked the Plan to provide coverage for these prosthetic components. You say that at the time of the appeal
this equipment was medically necessary. The Plan denied your request. The Plan says Medicare coverage
criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that
Maximus did not apply the correct Medicare guidelines.
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 these items. There are no medical
records from a licensed physician that at the time of the appeal, the enrollee was a K3 ambulator. Regardless of
whether or not the enrollee had the potential to achieve K3 ambulation, Medicare rules are clear that those
criteria must be met for approval at the time of the request. Medicare coverage criteria were not met. Therefore,
we decided that the Plan does not have to provide coverage for the requested prosthetic components.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bioimpedance spectroscopy for the enrollee.
You asked the Plan to pre-approve this service . You say that bioimpedance spectroscopy is medically
necessary. The Plan denied your request. The Plan says bioimpedance spectroscopy is not covered by
Medicare for the enrollee's diagnosis. 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. At the time of the Plan's denial, the
NCCN Guidelines Version 1.2022 Survivorship: Lymphedema did not recommend BIS in the management of
lymphedema. The available evidence in the medical literature was insufficient to support that bioimpedance
spectroscopy is medically reasonable and necessary. Therefore, we decided that the Plan does not have to preapprove
bioimpedance spectroscopy for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for the Rifton Tram lift for the enrollee. 

You asked the Plan to provide coverage for the Rifton Tram lift. You say that at the time of the appeal, this equipment was medically necessary for the enrollee.  The Plan denied your request. The Plan says Medicare coverage criteria were not met. Maximus overturned the Plans denial for insufficient information in the case file. The Plan requested a reopen and provided additional information. 

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. It is noted that the appeal states "the enrollee is not using the equipment for transfers, he is using for assist in standing, to work his core, back and legs to the stretch and exercise he needs by walking from this position." As this equipment is clearly being used for self-help and or to exercise, Medicare coverage criteria are not met. Therefore, we decided that the Plan does not have to provide coverage for the Rifton Tram lift for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for an electronic connection between wheelchair
controller and two or more power seating system motors (E2311) and a manual swing away, retractable or
removable mounting hardware for joystick, other control interface or positioning accessory (E1028).
You asked the Plan to provide coverage these accessories. You say that these accessories are medically
necessary. The Plan denied your request. The Plan says Medicare coverage criteria 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 these accessories. The medical records show the enrollee shows upper extremity strength and function that
is adequate to control the power options using their own switch, which is included in the allowance of these
power options. Because enrollee can the control of the power tilt through its own switch, there is no need to
control this power option through the joystick. Since the option joystick is not necessary, the E1028 swing
away interface for joystick is also not necessary. Therefore, we decided that the Plan does not have to provide
coverage for an electronic connection between wheelchair controller and two or more power seating system
motors (E2311) and a manual swing away, retractable or removable mounting hardware for joystick, other
control interface or positioning accessory (E1028).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair with additional accessories (E1028,
E2300, E2311, E2313, E2377).
You asked the Plan to pre-approve the requested equipment. . You say that at the time of the appeal, this
equipment was medically necessary for the enrollee. The Plan denied your request. The Plan says while the
power wheelchair was approved the requested accessories do not meet Medicare coverage criteria. Maximus
partially overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the
correct coverage criteria.
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.
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 the requested equipment. have been
met.  Therefore, we decided that the Plan does not have to pre-approve a power wheelchair with additional
accessories (E1028, E2300, E2311, E2313, E2377).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for the requested prosthetic components.
You asked the Plan to provide coverage for the requested prosthetic components for the enrollee. You say that
these components are medically necessary for the enrollee. The Plan denied your request. The Plan says the
Medicare coverage criteria are not met. Maximus partially 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 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. Medicare has specific documentation
requirements for prosthetic equipment. The current K2 prosthetic appears to be less than a year old. There is no
indication the provider was contact to determine if the components needing replacement are under warranty.
Medicare will not pay for replacement components that have the potential to be under warranty with the
original provider.
The medical records do not specifically state the enrollee is a K3 ambulator. Having the potential to be a K3
ambulator means limited adjustments would be needed to transition the enrollee from a K2 prosthetic to a K3
prosthetic. The records show the enrollee is using a walker for ambulation, which is not consistent with a K3
ambulator even if the K2 prosthetic requires adjustment. Medicare coverage criteria were not met.
Therefore, we decided that the Plan does not have to provide coverage for the requested replacement prosthetic
components.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power seat elevation system (E2300). 
 
You asked the Plan to pre-approve power seat elevation system. You say that the item is necessary. The Plan 
denied your request. The Plan says the requested item is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature (E2300) and 
power standing feature (E2301) are non-covered because they are not primarily medical in nature. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of power seat elevation system have not been met. Therefore, we decided that the Plan does not have 
to pre-approve power seat elevation system (E2300).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for K0108 (other accessories) and Function Push
Button AAM Module B for the enrollee.
You asked the Plan to provide coverage for power wheelchair repairs for the enrollee. all of the requested
repairs. You say that these repairs are necessary for the enrollee. The Plan partially denied your request. The
Plan says while a portion of this request (K0040, K0739x2, and tech assistance) was approved, the remaining
accessories and Function Push Button AAM Module B were denied. 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 will not repair power
wheelchair accessories that were not approved by Medicare when the equipment was originally approved. The
denied accessories were not approved with original issue of the power wheelchair. Therefore, we decided that
the Plan does not have to provide coverage for power wheelchair repairs for the enrollee to K0108 (other
accessories) and Function Push Button AAM Module B for the enrollee.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vabysmo.

You asked the Plan to pre-approve Vabysmo. You say that this is medically necessary. The Plan denied your request. The Plan says step therapy criteria have not been met.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.

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 Vabysmo. Our reviewer says that the requirements for coverage of Vabysmo have not been met. Our physician reviewer found the Plan requires a trial of Avastin/bevacizumab before they will approve Vabysmo. In this case, the enrollee has not tried and failed the required drug. There is no documentation provided indicating that the plan's required drug would likely be less effective or have adverse effects for the enrollee.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Vabysmo have not been met. Therefore, we decided that the Plan does not have to pre-approve Vabysmo.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a K3 ankle and foot features for a lower limb
prosthesis (L5981, L5986).
You asked the Plan to provide coverage for a K3 ankle and foot features for a lower limb prosthesis (L5981,
L5986).
The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the
Plans dental. 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 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 the requested prosthetic
components. The medical records show the enrollee was a K2 level of activity at the time of the appeal. The
medical records show the enrollee was using a walker and a wheelchair for both home and community
ambulation. This is not consistent with a K3 ambulator. The enrollee also shows several health issues that are
not consistent with a K3 ambulator. These comorbidities include, CVA, CAD, TMA on the contralateral foot,
ESRD. There are no medical records from the physician to show that member is K3 ambulator.
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 the requested components have been
met. Therefore, we decided that the Plan does not have to provide coverage for a K3 ankle and foot features for
a lower limb prosthesis (L5981, L5986).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a genicular nerve block rendered on December 29, 2022.

You asked the Plan to pay for the block. You say that the denied services should be reconsidered. The Plan denied your request. The Plan says this service does not meet the requirement of the plan of benefits and is excluded from coverage.

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 pay for the block. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that this is an experimental procedure that is the subject of ongoing clinical trials. Its role in the management of knee osteoarthritis is still being evaluated. 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 block have not been met. Therefore, we decided that the Plan does not have to pay for a genicular nerve block rendered on December 29, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that you are unable to stand without assistance and are completely weak on your left side. The Plan denied your request. The Plan says admission to the 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 does not require an acute 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, and an intensive rehabilitation therapy program. While you may have a need for physical therapy and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve an IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150, 87481, 87653, and 87641 billed for date of service August 22, 2022.

You asked the Plan to pay for procedure codes 87150, 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 87150, 87481, 87653, and 87641 is bundled into payment for other codes.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.
In this case, we have confirmed that code 87150 is a column II code to column I code 87500
We have confirmed that code 87481 is a column II code to column I codes 87150 and 87801.
We have confirmed that code 87653 is a column II code to column I codes 87150 and 87801.
We have confirmed that code 87641 is a column II code to column I codes 87150 and 87801.

This claim has not been billed with an appropriate modifier to bypass the edit. 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 87150, 87481, 87653, and 87641 billed for date of service August 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve expandable controller (E2377)
with harness (E2313) and electric connection (E2311)
You asked the Plan to pre-approve expandable controller (E2377) with harness (E2313) and electric connection
(E2311). You say that at the time of the appeal, this equipment was medically necessary. The Plan denied your
request. The Plan says Medicare coverage criteria were not met. Maximus overturned the Plans denial. The
Plan requested a reopen and stated that Maximus did not apply the correct criteria.
The Plan must follow Medicare rules. Medicare has specific coverage criteria for power wheelchair
accessories. Based on the medical records provided, the requested accessories exceed the enrollees use of this
equipment in the home. The power features come with their own switches. This eliminates the need for the
power options to be operated through a joystick. The medical records also show the enrollee is able to
independently use the switches to operate the current power options. Based on this information, Medicare
criteria for the accessories requested are not met. Therefore, we decided that the Plan does not have to preapprove
expandable controller (E2377) with harness (E2313) and electric connection (E2311).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical access to an implant body (second stage 
implant surgery) (D6011). 
 
You asked the Plan to pre-approve 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. 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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
surgical access to an implant body (second stage implant surgery) (D6011).