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

We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with single power option
(K0856) and accessories.

You asked the Plan to pre-approve a Group 3 power wheelchair with single power option and accessories. You
say that you need this power wheelchair for your mobility. The Plan denied your request. The Plan says that
you do not have a medical need for a Group 3 power wheelchair with a single power option.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for a Group 3 power
wheelchair with single power option and accessories. Our Medical Director states that you have right sided
hemiplegia/hemiparesis due to a stroke. You are modified independent with transfers and are able to ambulate
20 feet with a quad cane. You do not meet criteria for a tilt feature, and thus do not meet criteria for a Group 3
power wheelchair with single power option. You are not at high risk for skin breakdown and do not have a
history of skin breakdown. There is no documentation of flap surgery. There is no documented spasticity, or
self-catheterization needs to meet recline criteria. You do not have increased tone or spasticity in the trunk or
lower extremities. Our Medical Director found that your condition does not meet criteria for coverage of a
Group 3 power wheelchair with single power option and accessories.

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 3 power wheelchair with single power option and accessories have not
been met. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair with
single power option (K0856) and accessories.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx DiffDx-Melanoma gene expression test 
(0090U) provided July 24, 2023.  
 
You asked the Plan to pay for the genetic testing. You say that the myPath Melanoma test is a covered 
Medicare benefit under Local Coverage Determination (LCD) MolDX: myPath Melanoma Assay L37879 and 
should be a covered benefit for the enrollee. The Plan denied your request. The Plan says while the test is 
covered by molecular diagnostics (MolDx) program when medically necessary, the Plans more specific 
Medicare clinical guidelines define when this test can be considered 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 pay for the genetic testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the medical records provided do not meet the medically necessary requirements and the test is 
not considered 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 the genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pay for the DecisionDx DiffDx-Melanoma gene expression test (0090U) provided July 24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electronic connection (E2311), expandable controller
(E2377), harness (E2313) and positioning belt/safety belt/pelvic strap (E0978) for the enrollee.

You asked the Plan to pre-approve an electronic connection, expandable controller, harness and positioning
belt/safety belt/pelvic strap. You say that these items are medically necessary. The Plan denied your request.
The Plan says that the seat belt is already included in the wheelchair and cannot be requested separately and
that the upgraded electronics are not medically necessary.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for an electronic
connection, expandable controller and harness. Our Medical Director states that the enrollee has post-polio
syndrome which resulted in lower extremity paralysis. Upper extremity range of motion is limited. Upper
extremity strength is noted to be two out of five on the Wheelchair and Seating Assessment Guide. Assistance
is needed for bathing, grooming, and upper extremity dressing. Feeding is independent. The enrollee's
physician writes that the upper extremity strength is one out of five. The clinical documentation does not
sufficiently support that an expandable controller, harness, and an electronic connection are medically
reasonable and necessary for the enrollee in this case. Our Medical Director found that the enrollee's condition
does not meet Medicare criteria for an electronic connection, expandable controller and harness.

We looked at this physician's review, the file, and 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 E0978 is listed under Column II, with approved Power Wheelchair Base Group 3 code
K0861 listed under Column I. Therefore, payment of seat belt and related supplies is included with the
approved Power Wheelchair Base Group 3 K0861. A separate request for the seatbelt is denied as unbundled.
Based on this information, we decided that Medicare rules for coverage of an electronic connection,
expandable controller, harness and positioning belt/safety belt/pelvic strap have not been met. Therefore, we
decided that the Plan does not have to pre-approve an electronic connection (E2311), expandable controller
(E2377), harness (E2313) and positioning belt/safety belt/pelvic strap (E0978) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99497 rendered on December 28, 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 use of the modifier was not supported. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found that 
modifier -59 is not confirmed for use with CPT 99497 and is not supported in this case. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99497 rendered on December 28, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Vabysmo (J2777). 
 You asked the Plan to pre-approve Vabysmo. You say that Vabysmo is a medical necessity for the enrollee. 
The Plan denied your request. The Plan says step-therapy rules for coverage of Vabysmo have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Vabysmo. Our reviewer says that 
treatment with Vabysmo is not medically reasonable and necessary in this case. Our physician reviewer found 
that the Plan requires a trial of drugs Byooviz and Avastin before they will approve the requested drug. The 
enrollee has not tried and failed the required drugs. There is no documentation indicating that the Plan's 
required drugs would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vabysmo have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Vabysmo (J2777).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (procedure codes 87798, 87640, 87653, 
and 87481) rendered on December 2, 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 denied codes remain not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
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 in terms of CPT 87798, this 
procedure code represents a "not otherwise specified" procedure. The medical records do not include 
documentation of tests billed under this procedure. 
 
As CPT 87798 was not reported correctly, the various other codes that are included with this code are 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for laboratory services (procedure codes 87798, 87640, 87653, and 87481) rendered on December 
2, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Entyvio pen (J3380). 
 You asked the Plan to pre-approve Entyvio. You say that Entyvio is a medical necessity for the enrollee. The 
Plan denied your request. The Plan says step-therapy rules for coverage of Entyvio have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Entyvio. Our reviewer says that 
treatment with Entyvio is not medically reasonable and necessary in this case. Our physician reviewer found 
that the Plan requires a trial of drug Remicade, Inflectra or infliximab, as well as Stelara, before they will 
approve the requested drug. The enrollee has not tried and failed the required drugs. There is no documentation 
provided indicating that the Plans required drugs would likely be less effective and/or likely have adverse 
effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Entyvio have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Entyvio pen (J3380).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telehealth visit (G0508) provided on July 10, 2023. 
 
You asked the Plan to pay for the telehealth visit (G0508). You say that the service should be covered. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the telehealth visit 
(G0508) provided on July 10, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee exceeds Medicare criteria 
for admission to an LTACH. The Plan denied your request. The Plan says the enrollee does not meet the 
requirements for admission to an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not already available 
and covered at the current facility. Transfer to the LTACH is not clinically advantageous. Completion of 
treatment at the current facility is 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a sacroiliac joint injection.

You asked the Plan to provide coverage for a sacroiliac joint injection. 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 is correct in this case. The Plan must follow Medicare rules. Medicare has specific coverage criteria
for this type of injection.

The medical records show the notes dated August 9, 2023, state the enrollee has chronic back pain which
radiates to his right leg (radiculopathy). This clearly does not meet the criteria stated in the Medicare rules.
Therefore, we decided that the Plan does not have to provide coverage for a sacroiliac joint injection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional therapeutic massage visits.

You asked the Plan to pre-approve additional therapeutic massage visits. You say that the massage therapy is
the only treatment that works and loosens up your muscles. The Plan denied your request. The Plan says that
this benefit has been exhausted. Maximus overturned the Plan's denial for lack of information. The Plan
requested a reopening and provided documentation to confirm you have exhausted your massage benefit for the
year. The Plan is correct in this case. The Plan has provided Explanation of Benefits showing you have used
your six visits for massage benefits. Therefore, we decided that the Plan does not have to pre-approve
additional therapeutic massage visits.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 10060-78 rendered on March 1, 2023. 
 
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 a qualifying service/procedure needs to be received and covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
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 medical record submitted 
does not include sufficient documentation to verify procedure and modifier billed. Modifier 78 represents an 
unplanned return to the operating room or procedure room during the global period of the initial procedure by 
the same physician.  The procedure report does not support the service was performed in operating room, as 
well as post operative procedure report from initial service.  
 
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 code 10060-78 rendered on March 1, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care (procedure code 99310) 
provided on August 18, 2022. 
 
You asked the Plan to pay for subsequent nursing facility care (procedure code 99310). You say that you are 
requesting the claim be reviewed and reprocessed for payment. The Plan denied your request. The Plan says the 
records do not support the services at issue in this case. 
 
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 99310 is subsequent nursing facility 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, 45 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 subsequent nursing facility care (procedure code 99310). Our 
reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer 
found the documentation does not support that high medical decision making was performed. Therefore, the 
procedure code 99310 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 subsequent nursing facility care (procedure code 99310) have not been met. 
Therefore, we decided that the Plan does not have to pay for subsequent nursing facility care (procedure code 
99310) provided on August 18, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health physical therapy and home health skilled 
nursing. 
 You asked the Plan to pre-approve home health services. You say that this 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 the enrollee 
does not require additional skilled nursing or rehabilitation services to effectively provide treatment, care, 
and/or services in order to improve the enrollees condition, perform a maintenance program to maintain the 
enrollees condition and/or prevent deterioration. The enrollee has been medically stable without any recent 
exacerbations of chronic medical problems or hospitalizations. 
 
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 physical therapy and home health skilled nursing.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for sclerotherapy of telangiectasia and incompetent veins 
provided on December 14, 2022. You asked the Plan to pay for sclerotherapy of telangiectasia and incompetent veins. You say that sclerotherapy 
of telangiectasia and incompetent veins was medically necessary. The Plan denied your request. The Plan says 
sclerotherapy of telangiectasia and incompetent veins is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that sclerotherapy of telangiectasia and incompetent veins 
is covered when the criteria listed in the Medicare rules section of this decision 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 pay for sclerotherapy of telangiectasia and 
incompetent veins. Our reviewer says that the requested sclerotherapy of telangiectasia and incompetent veins 
is not considered medically reasonable and necessary in this case. Our physician reviewer found the patient 
underwent cosmetic sclerotherapy of spider veins as documented in the medical record. Cosmetic procedures 
are not covered by the health Plan. The documentation does not include information suggesting the procedure 
was 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 sclerotherapy of telangiectasia and incompetent veins have not been met. 
Therefore, we decided that the Plan does not have to pay for sclerotherapy of telangiectasia and incompetent 
veins provided on December 14, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 billed for February 10, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 99285 is not supported. 
 
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 99285 is emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high level 
of medical decision making. 
 
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 these services. Our reviewer says that procedure code 99285 
is not supported. Our reviewer found the submitted medical records do not support that medical decision making of high complexity was performed. Code 99285 is therefore 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99285 billed for February 10, 2023.