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

 
We decided that the Plan does not have to pre-approve Bevacizumab. 
 
You asked the Plan to pre-approve Bevacizumab. You say that the enrollee received Abraxane and did not 
tolerate it well and that recent data shows that Bevacizumab can be an option for squamous cell lung cancer. 
The Plan denied your request. The Plan says the services are 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 Bevacizumab. Our reviewer says that 
the medication is not medically necessary. Our physician reviewer found the FDA has not stated that the 
requested drug is indicated for the enrollee's condition.  The Medicare approved cancer drug compendia do not 
contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. No literature 
from Medicare approved cancer journals were submitted for review. The elements of the coverage criteria are 
not satisfied. The requested service cannot be 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 Bevacizumab have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Bevacizumab.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services.  

You asked the Plan to pre-approve home health services. You say that you would like to request 
reconsideration of the denied authorization. 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 services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the clinical 
documentation does not support the medical necessity of 5 additional home health skilled nursing visits and 2 
additional home health speech therapy visits. 
 
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 not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on January 6, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you disagree with the denial. 
The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related laboratory 
testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on January 
6, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 3, 2020 to February 
3, 2022, billed with codes 81206, 81210, 81235, 81272, 81275, 81276, 81301, and 81311. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the denial. The Plan 
denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
February 3, 2020 to February 3, 2022, billed with codes 81206, 81210, 81235, 81272, 81275, 81276, 81301, 
and 81311.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 9 months continued use of home ventilator, any type, 
used with non-invasive interface (E0466). 
 
You asked the Plan to pre-approve a ventilator. You say that you are appealing the denial of the ventilator as it 
is medically necessary for you The Plan denied your request. The Plan says under Medicare, the request for 
continued use of non-invasive ventilator (NIV) is not medically reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found continuation of the home ventilator is not medically necessary. This enrollee has had a home 
ventilator for an undetermined period of time. There is a diagnosis of COPD, but there are no pulmonary 
function tests or other clinical data to support the diagnosis. The medical record does not include a recent 
clinical visit documenting use and benefit from the device.  A compliance report covering April 26, 2023, to 
May 25, 2023, showed use of the device for at least 4 hours a day on 37% of days, which does not meet 
minimum Medicare criteria, and is insufficient use to benefit from the device.  Medicare does not cover a home 
ventilator when used at settings that can be provided with the device has been approved for 3 months which 
allows time to transition to BiPAP. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 9 months continued use of home ventilator, any type, used with non-invasive interface 
(E0466).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve OssDsign Catalyst Nano allograft (20930). 
 
You asked the Plan to pre-approve OssDsign Catalyst Nano allograft. You say that this is medically necessary. 
The Plan denied your request. The Plan says the clinical value and effectiveness of the OssDsign Catalyst Nano 
Allograft in the setting of lumbar spine fusion surgery have not been demonstrated in the peer-reviewed 
literature. 
 
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 OssDsign Catalyst Nano allograft. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found OssDsign Catalyst allograft is experimental in spine surgery. More 
research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of OssDsign Catalyst Nano allograft have not been met. Therefore, we decided 
that the Plan does not have to pre-approve OssDsign Catalyst Nano allograft (20930).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oxygen concentrator (E1390). 
 
You asked the Plan to pre-approve an oxygen concentrator. You say that you do not understand why the 
oxygen concentrator was denied but the portable oxygen was approved. The concentrator is needed more. The 
Plan denied your request. The Plan says medical records did not show this equipment was medically necessary. 
 
The Plan must follow Medicare rules. The rules say that oxygen is coverable when medically necessary for 
patients with significant hypoxemia who meet certain blood gas evidence requirements. In addition, the patient 
must have tried other alternative treatments without complete success. The patient must meet one of the 
following blood gas levels: 
 
1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest; 
 
2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during 
sleep for a patient who have hypoxia symptoms during sleep; 
 
3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for 
patients who have hypoxia symptoms during exercise; 
 
4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of 
dependent edema, pulmonary hypertension, or erythrocythemia. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an oxygen concentrator. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the coverage criteria for an oxygen concentrator has not been met by the provided 
documentation. The provided records do not have desaturation at rest and therefore the enrollee does not 
require an oxygen concentrator or oxygen at rest. Both the coverage rules and medical guidelines 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 an oxygen concentrator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an oxygen concentrator (E1390).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve electronic connection between wheelchair controller and 
2 or more power seating system motor (E2311) expandable controller (E2377) harness upgrade (E2313). 
 
You asked the Plan to pre-approve upgraded electronics. You say that please review the attached medical 
documentation to support the need of the custom medical equipment being requested for the enrollee. The Plan 
denied your request. The Plan says the requested upgraded electronics 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.  
 
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 upgraded electronics. 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 adequate upper body 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 upgraded electronics have not been met. Therefore, we decided that the Plan 
does not have to pre-approve electronic connection between wheelchair controller and 2 or more power seating 
system motor (E2311) expandable controller (E2377) harness upgrade (E2313).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an electronic connection between wheelchair controller and 2 or 
more power seating system motors (E2311), a harness (E2313) and an expandable controller (E2377). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that the accessories are all medically 
necessary. The Plan denied your request. The Plan says that Medicare guidance says that upgraded electronics 
(expandable controller, harness and electronic connector to 2 power options) are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve wheelchair accessories. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found the operative LCD L33792 and Policy Article A52504 are non-specific on the 
documentation requirements to allow coverage of the addition codes in question here, apart from being 
generally allowed for issue with a new group 3 chair, which has already been quite rightly approved by the 
Plan. Meanwhile, the physical therapist (PT)/medical doctors (MDs) appeal letter from June 26, 2023, and 
clinic note from May 13, 2023, do a thorough job of explaining the medical necessity for the complete set-up of 
the requested chair, including the need for simple control of multiple features to include power recline to help 
the enrollee unweight his bottom and prevent/treat pressure sores and elevate his legs for edema.  The 
reasonable and necessary criteria in Chapter 13 of the Program Integrity Manual are thoroughly satisfied for 
this request. Given this enrollees history and poor function in the absence of this chair and its carefully 
arranged features, there is every reason to expect that traditional Medicare would cover the entirety of this 
request which meets his medical needs now and into the future. Therefore, E2377, E2311, and E2313 are 
hereby approved. 
 
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 been met. Therefore, we decided that the Plan has 
to pre-approve an electronic connection between wheelchair controller and 2 or more power seating system 
motors (E2311), a harness (E2313) and an expandable controller (E2377).  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nine months continued use of a noninvasive ventilator 
(E0466). 
 
You asked the Plan to pre-approve a ventilator. You say that the medical records provided will show proof of 
medical necessity.  The Plan denied your request. The Plan says under Medicare, the request for continued use 
of non-invasive ventilator (NIV) is not medically reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 
 
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 ventilator. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found continuation of the home ventilator is not medically necessary. This enrollee has had a home 
ventilator since 2018. A recent compliance report shows 100% use of the device for at least 4 hours a day. 
There is a diagnosis of COPD and asthma, but there are no pulmonary function tests to assess the severity of 
airways obstruction. There are no arterial blood gases documenting chronic carbon dioxide (CO2) retention. 
There is no documentation that BiPAP with average volume-assured pressure support (AVAPS) has been tried 
and failed as an outpatient. Medicare does not cover a home ventilator when used at settings that can be 
provided with BiPAP. The current device has been approved for 3 months which allows time to transition to 
BiPAP.  
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve nine months continued use of a noninvasive ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Practitioner services provided on November 16, 2022, billed 
with code P9603. 
 
You asked the Plan to pay for the Practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed code. 
 
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 code P9603 is travel allowance one way in connection with 
medically necessary laboratory specimen collection drawn from home bound or nursing home bound patient; 
prorated miles actually travelled. 
 
We find that CPT code P9603 is not supported in the medical record. Specifically, the submitted 
documentation did not contain any travel documentation details to support travel allowance. Based on this 
information, we decided that Medicare rules for coverage of the Practitioner services provided have not been 
met. Therefore, we decided that the Plan does not have to pay for Practitioner services provided on November 
16, 2022, billed with code P9603.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 power wheelchair and accessories for the enrollee.
You asked the Plan to pre-approve a Group 3 power wheelchair and accessories. You say that this is medically necessary. The Plan denied your request. The Plan says that the member does not have a neurological condition, myopathy or congenital skeletal deformity which is causing mobility impairment for which a Group 3 power wheelchair is reasonable and necessary. Maximus overturned the Plan's denial. The Plan requested a reopening and stated that Maximus did not apply the correct criteria.
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for enrollees who have a mobility limitation that is due to: 1. A neurological condition; 2. Myopathy; or 3. Congenital skeletal deformity. The file does not show that the enrollee has a mobility limitation that is due to a neurological condition, myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair and accessories for the enrollee.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an expandable controller, harness, and electronic connection 
device for a power wheelchair. 
 
You asked the Plan to pre-approve expandable controller harness, and electronic connection device. You say 
that you desperately need this. The Plan denied your request. The Plan says that there is not a medical necessity 
to control your wheelchair's power options through a joystick. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve expandable controller harness, and 
electronic connection device. Our reviewer says that the requested items/services are considered medically 
reasonable and necessary in this case. Our physician reviewer found you have spasticity in the left upper and 
lower extremities. You cannot perform pressure relief independently due to upper extremity weakness and 
spasticity and require a power wheelchair with power tilt and recline for adequate pressure relief and 
positioning. You require power elevating leg rests for positioning of the lower extremities. An expandable 
controller with harness and electronic connection are needed to operate the Group 3 power wheelchair base and 
the 3 power options via a joystick. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of expandable controller harness, and electronic connection device have been met. 
Therefore, we decided that the Plan has to pre-approve an expandable controller, harness, and electronic 
connection device for a power wheelchair.  
 
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.