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

 
We decided that the Plan does not have to pre-approve a group 1 standard power operated vehicle (POV) 
(K0800). 
 
You asked the Plan to pre-approve a group 1 standard POV. The Plan denied your request. The Plan says this 
request is not medically necessary because the records do not show documentation as to your ability to safely 
transfer to and from or maneuver a POV, nor documentation of failed trial with other mobility assistive 
devices. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 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 1 standard POV. Our reviewer 
says that this request is not medically necessary. Our physician reviewer found the documentation available for 
review does not support that you require a power mobility device to accomplish mobility related self-care tasks 
in the home. Our reviewer also found that there is no indication that you are unable to use an alternative 
assistive device. 
 
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 1 standard POV have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a group 1 standard power operated vehicle (POV) (K0800).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code J7323 billed for date of service March 11, 
2022.  
 You asked the Plan to pay for procedure code J7323. The Plan denied your request. The Plan says the number 
of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code J7323 is 2. The MAI value for this code is 2. You billed 3 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code J7323 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code J7323 billed for date of service March 11, 2022.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for the home health care billed for dates of service October 25, 2022, to 
November 17, 2022. 
 
You asked the Plan to pay for the billed services. You say that the NOA was filed timely. The Plan denied your 
request. The Plan says that the NOA was not submitted timely. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
We looked at the file and the rules. In this case, the start of care date is July 22, 2022. The case file shows that 
an NOA was submitted and accepted on July 24, 2022. There is no documentation to show that this NOA was 
not suitable for payment. The Plan has not made reasonable and diligent efforts to gather and forward to us 
information regarding their decision to deny your request.  Therefore, we decided that the Plan has to pay for 
the home health care billed for dates of service October 25, 2022, to November 17, 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 pre-approve a CardioMEMS device. 
 
You asked the Plan to pre-approve a CardioMEMS device. You say that this device is medically necessary for 
the enrollee. The Plan denied your request. The Plan says there is not enough evidence showing the requested 
device would improve the outcome for your condition. 
 
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 a CardioMEMS device. Our reviewer 
says that the requested CardioMEMS device is not considered medically reasonable and necessary in this case. 
Our physician reviewer found CardioMEMS device is still an investigational phase and have not proven to be 
effective in improving morbidity/mortality in any RCTs (Randomized Clinical Trial). Therefore, the reviewer 
found that this device is not medically reasonable or 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 a CardioMEMS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies.  
 
You asked the Plan to pre-approve incontinence supplies. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the services are not covered. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97530 billed for date of service March 14, 
2023. 
 
You asked the Plan to pay for procedure code 97530. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says the provided records do not support the service 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 code 97530 is: Therapeutic activities, direct (one-on-one) 
patient contact (use of dynamic activities to improve functional performance), each 15 minutes. 
 
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 procedure code 97530. Our reviewer says that procedure 
code 97530 does not meet criteria for payment. Our reviewer found that the provided procedure report does not include sufficient documentation to confirm therapeutic activities performed and time spent for each activity, as 
these criteria were not documented in medical record. Procedure code 97530 cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 97530 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 97530 billed for date of service March 14, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) (64633, 64634). 
 
You asked the Plan to pre-approve the RFA procedures. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the documentation does not support that the enrollee has 
had 80% pain relief from two medial branch blocks. 
 
The Plan follows Medicare rules. Medicare rules say that an initial thermal radiofrequency ablation (RFA) of 
cervical, thoracic, or lumbar paravertebral facet joint (medial branch) nerves is considered medically 
reasonable and necessary for patients who have had at least two (2) medically reasonable and necessary 
diagnostic medial branch blocks (MBBs), with each one providing a consistent minimum of 80% sustained 
relief of primary pain. 
 
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 RFA procedures. Our reviewer says 
that the requested RFA is not medically necessary. Our physician reviewer found the provided documentation 
indicates the enrollee has their first diagnostic medial branch block (MBB) at bilateral T8 to T10 with 100% pain relief. The reviewer found that another diagnostic MBB at T5 to T7 also provided 100% pain relief. The 
reviewer found that the documentation does not include evidence of a second set of MBBs at either T5 to T7 or 
T8 to T10. Therefore, the reviewer found that the requested RFA is not medically reasonable or necessary at 
this time. 
 
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 RFA procedures have not been met. Therefore, we decided that the Plan 
does not have to pre-approve radiofrequency ablation (RFA) (64633, 64634).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care billed for dates of service July 28, 
2022, to August 26, 2022. You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the NOA was 
not received timely. As such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is June 28, 2022. The NOA was not received by the Plan until October 14, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health care billed for 
dates of service July 28, 2022, to August 26, 2022.
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 it is medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found you have been 
receiving home health therapy. You are noted to be ambulating with a walker and the documentation does not 
indicate that you have had a recent functional decline. You may require supervision and assistance with 
mobility and daily activities, but this should be provided in your assisted living facility and does not require the 
services of a skilled therapist. 
 
Therefore, the additional home health services/therapy is not medically 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasound-guided image guided radiation therapy. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found when treating skin cancers, there is 
generally not a need for IGRT unless deep structures are being treated. The use of ultrasound on a daily basis is 
not the standard of care for the enrollee's diagnosis and is not reasonable or medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve ultrasound-guided image guided radiation therapy.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion subcutaneous cardiac rhythm monitor 
(33285). 
 
You asked the Plan to pre-approve the implantable loop recorder (ILR). You say that this is covered for 
cryptogenic stroke as well as atrial fibrillation. You also say this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary for the enrollee. 
 
The Plan follows Medicare rules. Medicare rules say that an ILR is used when syncope is thought to be 
cardiac-related but is too infrequent to be detected by either a HolterTM monitor or a traditional pre-symptom 
MLR. 
 
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 implantable loop recorder (ILR). 
Our reviewer says that the requested ILR device is not medically necessary. Our physician reviewer found the 
provided documentation does not indicate a recent history of syncope, cryptogenic stroke, or prolonged 
inconclusive noninvasive monitoring. Therefore, the reviewer found that the requested ILR device is not 
medically reasonable or 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 implantable loop recorder (ILR) have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the insertion subcutaneous cardiac rhythm monitor (33285).
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the crown (D2740) for tooth #30. We decided that the Plan does 
not have to pre-approve the core buildup (D2950) and the prefabricated post (D2954) for tooth #30.  
 
You asked the Plan to pre-approve a crown (D2740), core buildup (D2950), and a prefabricated post (D2954) 
for tooth #30.. You say that the requested dental services are for a different tooth. The Plan says that your 
benefit limit for the crown has been exhausted. Also, the core buildup and the prefabricated post are not 
covered by the Plan. 
 
We decided that the Plan has to pre-approve the crown (D2740) for tooth #30.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. There is no evidence showing your benefit for the crown was previously exhausted. 
Therefore, we decided that the Plan has to pre-approve the crown (D2740) for tooth #30.  
 
We also decided that the Plan does not have to pre-approve the core buildup (D2950) and the 
prefabricated post (D2954) for tooth #30. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the core buildup and the prefabricated 
post are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-
approve the core buildup (D2950) and the prefabricated post (D2954) for tooth #30. 
 
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 pre-approval for a power seat elevation system (E2300). 
 
You asked the Plan to pre-approve a power seat elevation system. You say that you disagree with the Plan's 
denial because you are unable to stand on your own, cannot sit under the standard size of a table, and cannot 
stand independently. The Plan denied your request. The Plan says this is not a Medicare covered feature. 
 
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature (E2300) is non-
covered because it is 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 a power seat elevation system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve pre-approval for a power seat elevation system (E2300).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation system 
(HFCWOD) (E0483). 
 
You asked the Plan to pre-approve a HFCWOD. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that HFCWO are covered for beneficiaries who meet 
specific criteria. 
 
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 HFCWOD. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found a HFCWOD is not medically necessary. 
There is inadequate evidence that this device is effective in the treatment of chronic obstructive pulmonary 
disease (COPD), and Medicare does not cover it for that diagnosis. 
 
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 HFCWOD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a high frequency chest wall oscillation system (HFCWOD) (E0483).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on October 27, 2022.
You asked the Plan to waive the copayment for the office visit. You say that you were never informed of what would take place at doctor visit and don't feel should have to pay. The Plan denied your request. The Plan says that this cost sharing was charged correctly.
Maximus overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan says that this claim denied under your Medicare benefit because you are Medicaid eligible. The Plan included documentation to show that you are Medicaid eligible. The Plan says that Medicare pays covered dually eligible beneficiaries' medical services first, because Medicaid is generally the payer of last resort. Medicaid may cover medical costs that Medicare may not cover or partially covers (such as nursing home care, personal care, and home- and community-based services). These services qualified under the Medicaid coverage. The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing and coverage information. Your contract states dual eligible enrollees will have services that are covered by either Medicare or Medicaid, but not by both. The services provided fall under your Medicaid coverage and not your Medicare coverage. The IRE does not have jurisdiction over your Medicaid benefits. Therefore, we decided that the Plan does not have to waive the copayment for the office visit provided on October 27, 2022.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an abdominal/pelvis computed tomography (CT) scan without contrast for the enrollee.
You asked the Plan to pre-approve a CT scan. You say that this service is medically necessary. The Plan denied your request. The Plan says that the CT scan is not medically necessary.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for an abdominal/pelvis computed tomography (CT) scan without contrast. Our Medical Director states that the documentation does not support that a repeat CT scan of the abdomen and pelvis was medically reasonable and necessary for the enrollee in this case. NCCN Guidelines Version 2.2023, Endometrial Carcinoma, states that a CT scan of the abdomen and pelvis is recommended based on symptoms or physical exam findings. The clinical documentation does not support that the enrollee had symptoms or abnormal findings on physical exam. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage for a CT scan.
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 CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve an abdominal/pelvis computed tomography (CT) scan without contrast for the enrollee.