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

 
We decided that the Plan does not have to pre-approve the power tilt seating system with power-elevating 
legrests.  
 
You asked the Plan to pre-approve the requested power wheelchair components . You say that the requested 
items are medically necessary.  The Plan denied your request. The Plan says the criteria for these items are not 
met.  
 
The Plan follows Medicare rules. Medicare rules say that power tilt seating with power-elevating legrests may 
be covered with a power wheelchair when the criteria from the Medicare rules section are met.  
 
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 power wheelchair 
components. Our reviewer says that the documentation does not support the need for the requested power 
wheelchair components.  Our physician reviewer found the enrollee has functional deficits. However, the 
documentation does not indicate that the enrollee has any pressure injuries or requires intermittent 
catheterization of the bladder or has spasticity that would necessitate power tilt or elevating leg rests.    
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 power wheelchair components have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the power tilt seating system with power-elevating legrests.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation feature (E2300) and expandable 
controller with harness and electronic connection device. 
 
You asked the Plan to pre-approve power wheelchair components. You say that this is medically necessary. 
The Plan denied your request. The Plan says these components are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Medicare rules say that a power seat elevation future (E2300) 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 power wheelchair components. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case.  Our physician reviewer found the enrollee does have use of the upper extremities and can operate and 
control the wheelchair's power options using the switches that are included in the base 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 power wheelchair components have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a power seat elevation feature (E2300) and expandable controller with 
harness and electronic connection device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a manual wheelchair with accessories (E0954, E0955, 
E0956, E0971, E0973, E0990, E1028, E1161, E2202, E2203, E2231, E2609, E2617, K0040, K0108). 
 
You asked the Plan to pre-approve the wheelchair. You say that this item is medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the wheelchair is being requested for use in a SNF or hospital.  Therefore, we decided that 
the Plan does not have to pre-approve a manual wheelchair with accessories (E0954, E0955, E0956, E0971, 
E0973, E0990, E1028, E1161, E2202, E2203, E2231, E2609, E2617, K0040, K0108).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the know error testing provided on September 7, 2022. 
 
You asked the Plan to pay for the know error testing. You say that this testing should be approved for payment. 
The Plan denied your request. The Plan says this is not a covered test. 
 
The Plan must follow Medicare rules. Medicare rules say that the know error testing is not covered by 
Medicare as it does not directly provide information to diagnose or treat a patient illness or injury.  Therefore, 
we decided that the Plan does not have to pay for the know error testing provided on September 7, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the two units of code A4253. representing 100 reagent test strips, 
provided on October 27, 2022.  
 
You asked the Plan to pay for the two units of A4253. You say that the proper number of supplies were 
delivered to the enrollee and should be reimbursed. The Plan denied your request. The Plan says that the MUE 
for code A4253 is 0 with an MAI of 3, which means that it cannot be covered by Medicare.  
 
Please note: Maximus reviewed the Durable Medical Equipment (DME) MUE chart and found that, in fact, 
code A4253 has an MUE of 1 unit, with an MAI of 3.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units. 
 
We looked at the file and Medicare rules. We find that the text of the LCD for Glucose Monitors serves as 
evidence justifying the excess units over the MUE. The LCD states that up to 100 test strips are covered for a 
3-month period for an enrollee not using insulin, and 300 test strips for an enrollee using insulin. Regardless of 
the period for which this order was provided, it is under the amount allowed per the LCD. We find that the 
medical necessity parameters from the LCD support coverage of units in excess of the MUE in this case. Based 
on this information, we decided that Medicare rules for coverage of the two units of A4253 have been met. Therefore, we decided that the Plan has to pay for the two units of code A4253. representing 100 reagent test 
strips, provided on October 27, 2022.   
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a kidney transplant evaluation to be provided by an out-
of-network (OON) provider.  
 
You asked the Plan to pre-approve an OON kidney transplant evaluation. The Plan denied your request. The 
Plan says there does not appear to be any reasoning for being seen at the OON facility when a participating 
facility is available and closer to you.   
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a kidney transplant evaluation to be provided by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance transportation provided on September 24, 
2021. 
 
You asked the Plan to pay for the ambulance transport. You say that a corrected claim was submitted and 
should be paid. The Plan denied your request. The Plan says the original claim was not submitted with a 
required secondary diagnosis.  
 
The Plan must follow Medicare rules. Medicare rules say that ambulance claims must report a secondary 
diagnosis code from the list in the rules.  
 
We looked at the file and Medicare rules. The claim was not billed with one of the required secondary 
diagnosis codes. Based on this information, we decided that Medicare rules for coverage of the ambulance 
transport have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance 
transportation provided on September 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory pathogen testing by nucleic acid provided on 
December 7, 2022. 
 
You asked the Plan to pay for the respiratory pathogen testing. You say that this was medically necessary 
testing.  The Plan denied your request. The Plan says the claim for this molecular pathology testing did not 
include the required unique identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the respiratory 
pathogen testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
respiratory pathogen testing by nucleic acid provided on December 7, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 20 additional occupational therapy visits. 
 
You asked the Plan to pre-approve the therapy services. You say that without further skilled therapy services, 
the enrollee is at significant risk for increased dependence with activities of daily living. The Plan denied your 
request. The Plan says the requested therapy is not medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the enrollee has been previously treated with outpatient therapies and 
should be independent with a home exercise program. There is no documentation of a recent injury or decline 
in function. The additional therapy services are not an appropriate duration and frequency for treatment of the 
enrollee's condition. 
 
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 services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 20 additional occupational therapy visits.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for the home health services provided on July 14, 2022, to August 4, 2022.  
 
You asked the Plan to pay for home health services. You say that the services were requested by the physician, 
and the need for them is clearly documented in the records. The Plan denied your request. The Plan says that 
there is no signed order for the skilled nursing services provided during this period. 
 
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 pay for home health services. Our reviewer says that 
the services are medically reasonable and necessary. Our physician reviewer found the enrollee is an 83-year-
old female with a medical history including hypertension and diabetes mellitus who received home healthcare 
services on the dates at issue. The documentation includes a progress note dated June 2, 2022, that indicates the 
enrollee had chronic lower back and bilateral knee pain with a recent hospitalization for a fall with knee injury. 
Additionally, the provider noted the enrollee's blood pressure was elevated. The provider changed her blood 
pressure medications and ordered home healthcare for monitoring and education. Additionally, the enrollee was 
receiving homecare for a diabetic foot wound with an eschar. 
 
The documentation does support that the enrollee required additional skilled nursing services on the dates at 
issue. The enrollee required home health services for the management of a diabetic foot wound, hypertension 
with recent medication changes and worsening knee pain. There was a signed plan 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 home health services have been met. Therefore, we decided that the Plan has to 
pay for the home health services provided on July 14, 2022, to August 4, 2022.   
 
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 pay for procedure codes 28270 and 99100 rendered on September 
26, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services 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. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 28270: 
 
Capsulotomy; metatarsophalangeal joint, with or without tenorrhaphy, each joint (separate procedure) 
 
CPT 99100: 
 
Anesthesia for patient of extreme age, younger than 1 year and older than 70 (List separately in addition to 
code for primary anesthesia procedure) 
 
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 says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the procedure report describes 
capsulotomy; metatarsophalangeal joint performed through same incision as an osteotomy, with or without 
lengthening, shortening or angular correction for multiple metatarsal (Swanson type cavus foot procedure. In 
this case, this procedure would be included in the primary procedure, CPT 38309 and modifier XU unusual 
non-overlapping service cannot be verified. 
 
We also find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means 
that procedure code 99100 is not separately payable. 
 
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 procedure codes 28270 and 99100 rendered on September 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation and management (EM) services provided on 
November 27, 2022, billed with code 99223-25. 
 
You asked the Plan to pay for the EM services as billed. You say that this should be payable.  The Plan denied 
your request. The Plan says the EM services were not billed correctly.  
 
The Plan must follow Medicare rules. Medicare rules say that to report the EM services during which the need 
for surgery is determined, modifier -57 must be used. 
 
We looked at the file and Medicare rules. The file shows the need for surgery was determined during the visit 
at issue. However, modifier -57 was not billed as required. Based on this information, we decided that 
Medicare rules for coverage of the EM services as billed have not been met. Therefore, we decided that the Plan does not have to pay for the evaluation and management (EM) services provided on November 27, 2022, 
billed with code 99223-25.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to approve 20 additional routine transportation trips. 
 
You asked the Plan to approve these services. You say that you need to complete physical therapy three times 
per week. The Plan denied your request. The Plan says you have exhausted the benefit limit. 
 
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 48 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. The file shows that you have used 46 of 
the 48 total one-way trips allowed by your supplemental routine transportation benefit. Once you have used all 
48 one-way trips, further trips are not covered by Medicare or your supplemental benefit. Therefore, we 
decided that the Plan does not have to approve 20 additional routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory pathogen testing by nucleic acid provided on 
December 10, 2022. 
 
You asked the Plan to pay for the respiratory pathogen testing. You say that this is a covered test which was 
provided for a covered indication. The Plan denied your request. The Plan says the claim for this molecular 
pathology testing did not include the required unique identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the respiratory 
pathogen testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
respiratory pathogen testing by nucleic acid provided on December 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory pathogen testing by nucleic acid provided on 
December 3, 2022.  
 
You asked the Plan to pay for the respiratory pathogen testing. You say that this was provided for a covered 
indication. The Plan denied your request. The Plan says the claim for this molecular pathology testing did not 
include the required unique identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the respiratory 
pathogen testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
respiratory pathogen testing by nucleic acid provided on December 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0482 provided on June 8, 2022. 
 
You asked the Plan to pay for procedure code G0482. 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 supported. 
 
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 G0482 have been met. 
In this case, the laboratory results were not provided for review. The laboratory results are required in order to 
verify that the correct procedure code was billed. Therefore, we decided that the Plan does not have to pay for 
procedure code G0482 provided on June 8, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with pembrolizumab and pamucirumab.  
 
You asked the Plan to pre-approve the requested combination treatment. You say that you feel that there is 
enough evidence to support this is needed.  The Plan denied your request. The Plan says the requested 
treatment order of pembrolizumab and pamucirumab is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 combination treatment. 
Our reviewer says that the requested combination treatment is not considered reasonable and necessary in this 
case.  Our physician reviewer found the requested treatment is not FDA-approved for the enrollee's condition. There is also no phase III data supporting this use in the major drug compendia or by clinical research that 
appears in a Medicare-approved medical journal. The evidence is not sufficient to support this treatment.  
 
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 combination treatment have not been met. Therefore, we decided 
that the Plan does not have to pre-approve treatment with pembrolizumab and pamucirumab.