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

We decided that the Plan does not have to provide coverage for a Prosthetic leg with an advance knee/foot
feature (L5828, L5845, L5848, L5850, L5981 and L5856).

You asked the Plan to provide coverage for the requested prosthetic equipment. You say that at the time of the
appeal, this prosthetic equipment was medically necessary. The Plan denied your request.

The Plan says the Medicare coverage criteria were not met. Maximus overturned the Plans denial. The Plan
requested a reopen and stated that Maximus did not apply the correct criteria. The Plan noted that the enrollee's
physician states a K3 foot and K3 knee is medically necessary as the enrollee is a K3 ambulator. However, this
is not consistent with available medical history. The medical records show the enrollee currently uses a
wheelchair. Previously member used a walker with the prosthesis. This is not consistent with K3 ambulation.
Medicare covers items that meet, but do not exceed, the member's need. The medical records do not show why
the enrollee requires a K3 knee and foot, or why a more standard knee and foot would not meet the enrollee's
needs. Therefore, the documentation does not demonstrate that enrollee is a K3 ambulator.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say the documentation
provided does not support that the enrollee was a K3 ambulator at the time of the appeal. Medicare rules for
coverage of the requested prosthetic equipment have not been met. Therefore, we decided that the Plan does
not have to provide coverage for a Prosthetic leg with an advance knee/foot feature (L5828, L5845, L5848,
L5850, L5981 and L5856).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional payment for eyeglasses provided on November
11, 2022.

You asked the Plan to provide additional payment for eyeglasses. You say that you urgently needed the second
pair of glasses, and they were not ready yet. The Plan denied your request. The Plan says that the claim
processed correctly. Maximus partially overturned the Plan's denial because of a lack of information. The Plan
requested a reopening and stated that you were covered for one pair of eyeglasses up to the $400 benefit
maximum. The Plan is correct in this case. Documentation provided indicates you received a pair of eyeglasses
on November 11, 2022, and that the Plan paid $400 towards them. The Plan rules state that only one pair of
eyeglasses are covered per year and that only $400 is provided for the eyeglasses. The Plan has paid up to the
maximum benefit for eyeglasses and a second pair are not covered per your benefit. Therefore, we decided that
the Plan does not have to provide additional payment for eyeglasses provided on November 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on February 27, 2023, billed 
with procedure code 99232. 
 
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 the billed code is not appropriate for the billed 
place of service. 
 
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 99232 is subsequent hospital inpatient or observation 
care, per day, for the evaluation and management of a patient, which requires a medically appropriate history 
and/or examination and moderate level of medical decision making. When using total time on the date of the 
encounter for code selection, 35 minutes must be met or exceeded.  
We find that CPT code 99232 is not supported in the medical record. Specifically, documentation indicates that 
the service was rendered in a skilled nursing facility. The billed code is inappropriate for services rendered in 
this setting. 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 February 27, 2023, billed with procedure code 99232.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that a lower level of care is not safe, sufficient, or 
equipped to address the enrollee's needs. You also say that the enrollee requires and has the potential for 
significant improvement with consistent intensive therapy 3 hours per day while under the oversight of the 
multidisciplinary team to ensure optimal recovery and prevent further decline. The Plan denied your request. 
The Plan says the service requested is not supported based on the records received.  
 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 the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. Our reviewer found while the medical record supports a need for 
physical 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. Our physician reviewer also found that 
there is not a reasonable expectation that this enrollee 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and related supply 
allowance. 
 
You asked the Plan to pre-approve the CGM and related supply allowance. You say that the CGM is medically 
necessary. The Plan denied your request. The Plan says the Medicare coverage criteria was not met. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the CGM and related supply allowance. 
Our reviewer says that the CGM coverage criteria was not met. Our physician reviewer found that the coverage 
criteria for a CGM requires insulin use or low blood sugars. This enrollee is not having low blood sugar levels 
that we are told of and is not on a medication that typically causes low blood sugars; hence, although a CGM 
may help the enrollee, the criteria for coverage of a CGM 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 the CGM and related supply allowance have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and related supply 
allowance.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0482 billed for date of service July 14, 
2023.  
 
You asked the Plan to pay for procedure code G0482. The Plan denied your request. The Plan says payment for 
code G0482 is bundled into payment for code 80307. 
 
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 G0482 is a column two code to column one code 80307 with a modifier indicator of 0. The column two code is 
therefore not payable. 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 code G0482 billed for date of service July 14, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you will require rehabilitation services to learn to do 
activities with one arm. The Plan denied your request. The Plan says IRF services are not required, and 
outpatient or skilled nursing facility services may be approved upon request.  
 
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. There are no complex 
nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record 
supports a need for physical 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat radiofrequency ablations (RFA) (64633, 64634). 
 
You asked the Plan to pre-approve repeat RFA. You say that you need this procedure in order to improve your 
condition. The Plan denied your request. The Plan says the records do not show that member has had consistent 
improvement of pain in her back. 
 
The Plan follows Medicare rules. Medicare rules say that repeat thermal facet joint radiofrequency ablation 
(RFA) at the same anatomic site is considered medically reasonable and necessary provided the patient had a 
minimum of consistent 50% improvement in pain for at least six (6) months. 
 
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 repeat RFA. Our reviewer says that the 
requested repeat RFA is not medically necessary. Our physician reviewer found the provided documentation 
does not indicate that you had 50% pain relief for at least 6 months, as required in the LCD. Therefore, the 
reviewer found that the requested repeat RFA 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 repeat RFA have not been met. Therefore, we decided that the Plan does not 
have to pre-approve repeat radiofrequency ablations (RFA) (64633, 64634).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intraosseous ablation of the basivertebral nerve. 
 
You asked the Plan to pre-approve the intraosseous ablation of the basivertebral nerve. You say that the 
enrollee has tried and failed conservative treatment without relief. The Plan denied your request. The Plan says 
the intraosseous ablation of the basivertebral nerve is 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 the intraosseous ablation of the 
basivertebral nerve. Our reviewer says that the intraosseous ablation of the basivertebral nerve is not medically 
necessary. Our physician reviewer found that the intraosseous ablation of the basivertebral nerve is considered 
experimental therapy. Therefore, the request is not medically reasonable and necessary. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the intraosseous ablation of the basivertebral nerve have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the intraosseous ablation of the basivertebral 
nerve.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a Dexcom G7 Mis receiver. 
 
You asked the Plan to pre-approve the Dexcom G7 Mis receiver. You say that the enrollee is no longer able to 
draw blood for finger prick. You also say that the Dexcom will benefit the enrollee as well as give his daughter 
the ability to track/monitor his testing results.  The Plan denied your request. The Plan says that a CGM is 
covered under Medicare only if a member with diabetes is on insulin or has documentation of very low blood 
sugars that has occurred several times.  
 
The Plan must follow Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the Dexcom G7 Mis receiver. Our 
reviewer says that this item is medically necessary. Our physician reviewer found although the enrollee is not 
having low blood glucose sugar we are told of, he is not able to monitor blood glucose sugar due to arthritis 
and not being able to get blood from his finger. The enrollee is not able to determine if blood glucose is low as 
he is 87, lives alone and has renal insufficiency with creatinine of 2.04. It is reasonable to be able to determine 
blood glucose level as he is at high risk for hypoglycemia given his age and glomerular filtration rate (GFR). 
Also, family members can monitor blood glucose sugar with the share function of Dexcom. 
 
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 Dexcom G7 Mis receiver have been met. Therefore, we decided that the 
Plan has to pre-approve a Dexcom G7 Mis receiver.  
 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ryaltris. 
 
You asked the Plan to pre-approve the medication. You say that this is medically necessary for the enrollee's 
treatment. The Plan denied your request. The Plan says the medication is not covered as a medical benefit 
under the Plan. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ryaltris.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a gastrointestinal (GI) tract capsule endoscopy (91110). 
 
You asked the Plan to pre-approve a GI tract capsule endoscopy. The Plan denied your request. The Plan says 
the enrollee's clinical condition does not meet criteria. 
 
The Plan follows Medicare rules. Medicare rules say that a diagnostic and/or surveillance CCE is medically 
necessary for the detection of colon polyps when either of the criteria listed in the Medicare rules section of this 
letter 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 a GI tract capsule endoscopy. Our 
reviewer says that the criteria for coverage have not been met. Our physician reviewer found a recent 
colonoscopy has not identified a lower gastrointestinal source of occult blood in stool. No recent upper 
endoscopy however has been performed since the October 28, 2021; study revealed a healthy appearing roux-
en-y gastrojejunostomy.   
 
Medical necessity and Medicare coverage criteria require a recent EGD (upper endoscopy) be performed prior 
to the requested repeat capsule testing in evaluation of presumed bleeding from the gastrointestinal tract. 
 
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 GI tract capsule endoscopy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a gastrointestinal (GI) tract capsule endoscopy (91110).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion or replacement of permanent cardiac 
contractility modulation (CCM) system (Optimizer Smart) (0408T). 
 
You asked the Plan to pre-approve the Optimizer Smart CCM. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the efficacy of the Optimizer System is still uncertain at 
this time according to leading authorities and not recommended in current guidelines for the treatment of heart 
failure. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Optimizer Smart CCM. Our 
reviewer says that the requested Optimizer Smart CCM is not considered medically reasonable and necessary 
in this case. Our physician reviewer found CCM remains the subject of multiple studies examining long-term efficacy, as well as randomized, controlled, double-blinded trials to quantify clinical efficacy. Until such 
statistically rigorous studies are completed, it is premature to presume clinical outcomes and benefit. Therefore, 
the reviewer found that the requested CCM system 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 Optimizer Smart CCM have not been met. Therefore, we decided that the 
Plan does not have to pre-approve insertion or replacement of permanent cardiac contractility modulation 
(CCM) system (Optimizer Smart) (0408T).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99233 billed for date of service June 24, 2023. 
 
You asked the Plan to pay for code 99233. You say that the medical records support the billing of code 99233. 
The Plan denied your request. The Plan says code 99233 was not supported by the medical record. This 
enrollee had an unremarkable night in the hospital and was discharged home the following day. As a result, this 
claim was downcoded to 99232. 
 
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 99233 is Subsequent hospital inpatient or observation 
care, per day, for the evaluation and management of a patient, which requires a medically appropriate history 
and/or examination and high level of medical decision making. When using total time on the date of the 
encounter for code selection, 50 minutes must be met or exceeded.  
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 code 99233. Our reviewer says that code 99233 is not 
supported by the medical record. Our reviewer found the enrollee is a 61-year-old female who presented to the 
emergency room with chronic obstructive pulmonary disease (COPD) exacerbation and was started on steroids, 
bronchodilators, antibiotics, and oxygen support. The next day she was reported to be responding to treatment 
with stable vitals and requiring additional oxygen weaning. Although the documentation supported an 
appropriate history and examination, it does not sufficiently support a high level of medical decision-making as 
the patient was stable and required only continued treatment as before without significant changes. Also, the 
duration of the encounter was not documented to be 50+ minutes in length. Therefore, code 99233 is not 
supported.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99233 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99233 billed for date of service June 24, 2023.