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

 
We decided that the Plan does not have to pre-approve the perrcutaneous transcatheter closure of the left atrial 
appendage with endocardial implant, including fluoroscopy, transseptal puncture, catheter placement(s), left 
atrial angiography, left atrial appendage angiography, when performed, and radiological supervision and 
interpretation (33340). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the documentation does not support a formal shared decision-making interaction with an independent non-interventional physician supporting that this procedure 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 the service. Our physician reviewer 
found the records do not document that a formal decision-making interaction with a non-interventional 
physician was performed. As such, guidelines would not support implantation of a LAAC in this setting. In 
summary, LAAC placement would not be considered reasonable or medically necessary in this enrollee's 
clinical management. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the perrcutaneous transcatheter closure of the left atrial appendage with endocardial 
implant, including fluoroscopy, transseptal puncture, catheter placement(s), left atrial angiography, left atrial 
appendage angiography, when performed, and radiological supervision and interpretation (33340).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nighttime personal care attendant services. 
 
You asked the Plan to pre-approve nighttime personal care attendant services. You say that you live alone and 
have difficulty seeing, especially at night. The Plan denied your request. The Plan says that this is not a 
Medicare covered benefit. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of nighttime personal care attendant services have not been met. Specifically, we find that the 
services at issue in this case are considered custodial in nature. Therefore, we decided that the Plan does not 
have to pre-approve nighttime personal care attendant services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87641, and 87653 billed for date of 
service November 16, 2022. 
 You asked the Plan to pay for procedure codes 87481, 87641, and 87653. The Plan denied your request. The 
Plan says payment for codes 87481, 87641, and 87653 is bundled into payment for code 87801. 
 
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 codes 
87481, 87641, and 87653 are column II codes to column I code 87801. This claim has not been billed with an 
appropriate modifier to bypass the edit. 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 codes 87481, 87641, and 87653 
billed for date of service November 16, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an electronic connection (E2311), harness (E2313), and 
expandable controller (E2377). 
 
You asked the Plan to pre-approve an electronic connection, harness, and expandable controller. The Plan 
denied your request. The Plan says that although there are three requested power options (tilt, recline and 
elevating leg rests), there is not a medical need to control these power options through the 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 an electronic connection, harness, and 
expandable controller. Our reviewer says that the expandable controller (E2377) with harness (E2313) and 
electronic connection (E2311) are medically necessary. Our physician reviewer found the enrollee is 
functionally non-ambulatory and requires a power wheelchair for mobility and performing her basic daily 
activities. The enrollee cannot perform pressure relief independently due to upper extremity weakness and 
requires a power wheelchair with power tilt for adequate pressure relief and positioning. Our reviewer found 
that the enrollee requires power elevating leg rests for positioning of their lower extremities and lower 
extremity edema. The enrollee requires a power seat elevator to be independent with transfers to and from the 
power wheelchair. The complexity of the enrollee's seating and positioning needs necessitates a more complex 
group 3 power wheelchair base. Our physician reviewer also found that the expandable controller with harness 
and electronic connection are necessary to operate the group 3 power wheelchair base and the three 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 an electronic connection, harness, and expandable controller have been met. 
Therefore, we decided that the Plan has to pre-approve an electronic connection (E2311), harness (E2313), and 
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 the home ventilator (E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the ventilator is medically necessary. The 
Plan denied your request. The Plan says the ventilator is not medically 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 the home ventilator. Our physician 
reviewer found the provided records document that the home ventilator is being requested for use in intelligent volume assured pressure support (IVAPS) mode with auto-EPAP (AE) which could be provided by a bilevel 
positive airway pressure (BiPAP) device with average volume assured pressure support (AVAPS) and a back-
up rate. Provided records do not document trial and failure of a BiPAP device with AVAPS and a back-up rate.  
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (E0466).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve JAK2 (Janus Kinase 2) targeted sequence analysis 
(81279). 
 
You asked the Plan to pre-approve JAK2 targeted sequence analysis. You say that this test is medically 
necessary and reasonable. The Plan denied your request. The Plan says this service is not medically necessary 
in this case, as the enrollee has not yet had results from a BCR-ABL test. 
 
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 JAK2 targeted sequence analysis. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the documentation shows that the BCR-ABL test has been approved. It is 
necessary to see the results of this test before determining whether or not JAK2 testing is necessary and 
appropriate. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of JAK2 targeted sequence analysis have not been met. Therefore, we decided that 
the Plan does not have to pre-approve JAK2 (Janus Kinase 2) targeted sequence analysis (81279).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for definitive urine drug testing (procedure code G0482) 
rendered on October 24, 2022. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says the documentation does not support that the services were 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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the records did not reveal an unexpected result from a point-of-care urine drug screening to justify 
follow-up with definitive testing. There was no report of suspected drug abuse/misuse, nor was there a need for 
more than 4 drug classes to be tested (benzo, opioid, anti-seizure, stimulant). There was no need for testing 
definitive testing for 15-21 drug classes.  
 
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 definitive urine drug testing (procedure code G0482) rendered on October 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for surgical placement of implants (D6010) tor tooth numbers 22 and 27.

You asked the Plan to provide coverage for these implants. You say that these services should be covered by the Plan.  The Plan denied your request. The Plan says the required coverage criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct coverage criteria. 

The Plan is correct. Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.


Though the Plan offers a dental benefit in excess of Medicare coverage, your medical records do not show you have a diagnosis for which implants are covered. Therefore, we decided that the Plan does not have to provide coverage for surgical placement of implants (D6010) for tooth numbers 22 and 27.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide care. 
 
You asked the Plan to pre-approve the aide services. You say that this is medically necessary. The Plan denied 
your request. The Plan says Medicare does not pay for custodial services. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the aide services. Our reviewer says 
that the services are not medically reasonable and necessary. Our physician reviewer found that you are medically stable. You have been ordered to have outpatient physical therapy services. You require custodial 
care, and are no longer receiving skilled care in the home. The requested home health aide services are 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 the aide services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve home health aide care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87500, 87150) provided on February 20, 2023. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the codes billed are not separately payable. 
 
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 find that CPT code 87500 & 87150 is not supported in the medical record. Specifically, 4 units of code 
87500 were billed. Only one unit is supported. Code 87150 is included in another service billed. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we 
decided that the Plan does not have to pay for lab services (87500, 87150) provided on February 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99291 billed for date of service October 29, 
2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says an appropriate 
modifier was not 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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. We find that CPT code 99291 was not billed with 
a modifier suitable for separate payment. Based on this information, we decided that Medicare rules for 
coverage of the billed services have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99291 billed for date of service October 29, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to make additional payment for the outpatient hospital services related 
to dental care provided from February 27, 2023, through March 1, 2023.  
 
You asked the Plan to make additional payment for the dental services. You say that it is felt that the claim was 
not processed correctly.  The Plan denied your request. The Plan says the services at issue are not covered by 
Medicare.  
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to make additional payment for involve the care, treatment, filling, 
removal or replacement of the enrollees teeth or the structures directly supporting the enrollees teeth. These 
are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to make additional payment for the outpatient hospital services related to dental care provided from 
February 27, 2023, through March 1, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nine (9) months of continued use of a home ventilator 
(E0466). 
 
You asked the Plan to pre-approve continued use of a home ventilator. You say that this device has kept the 
enrollee from repeatedly readmitting due to hypoxemia and hypercapnia. The physician has made it clear that 
the settings the enrollee has been prescribed are not achievable by any device except the home ventilator 
prescribed. The Plan denied your request. The Plan says the request for continued use of non-invasive 
ventilator (NIV) is not medically reasonable and necessary. The documentation indicates that this device is 
being used solely for bilevel pressure delivery or BiPAP mode, and thus it is being used solely as a respiratory 
assist device. 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 continued use of a home ventilator. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee has severe 
obesity with obesity hypoventilation syndrome. The enrollee was provided with a ventilator in the AVAPS-AE 
mode following a hospitalization in 2018. It appears this enrollee's ventilatory needs could be met with BiPAP 
with AVAPS-AE. Medicare does not cover a home ventilator when used at settings that can be provided with 
BiPAP. The plan has approved the ventilator for 3 months, which provides time for 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 continued use of a home ventilator have not been met. Therefore, we decided 
that the Plan does not have to pre-approve nine (9) months of continued use of a home ventilator (E0466).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81321, 81351, and 81406) provided on 
September 26, 2022. 
 
You asked the Plan to pay for the lab services. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (81321, 81351, and 81406) provided on September 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87652 billed for date of service October 24, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the test was ordered by the treating physician. 
The Plan denied your request. The Plan says the testing does not meet the coding criteria. 
 
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 87652 is infectious agent detection by nucleic acid (DNA 
or RNA); Streptococcus, group A, quantification. 

We find that CPT code 87652 is not supported in the medical record. There is a more applicable code that 
describes the Streptococcus testing provided. Based on this information, we decided that Medicare rules for 
coverage of the billed services have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 87652 billed for date of service October 24, 2022.
Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve high frequency chest wall oscillation system (E0483). We 
decided that the Plan does not have to pre-approve the home ventilator (E0466) .  
 
You asked the Plan to pre-approve the home ventilator (E0466) and high frequency chest wall oscillation 
system (E0483).. You say that the DME is medically necessary. The Plan says that the DME is not medically 
necessary. 
 
We decided that the Plan has to pre-approve high frequency chest wall oscillation system (E0483).  
 
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 high frequency chest wall 
oscillation system (E0483). Our reviewer says that the provided records in this case document the enrollee has 
bronchiectasis on imaging and a daily productive cough for at least six (6) continuous months despite use of 
Mucinex, inhalers, nebulizers, a flutter valve and chest physiotherapy. The high frequency chest wall 
oscillation system meets coverage criteria as required by the LCD L33785. 
 
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 DME have been met. Therefore, we decided that the Plan has to pre-approve 
high frequency chest wall oscillation system (E0483).   
We also decided that the Plan does not have to pre-approve the home ventilator (E0466) . 
 
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 home ventilator (E0466). Our 
reviewer says that the provided records document that the home ventilator is being requested for use in a 
pressure support mode which could be provided by a bilevel positive airway pressure (BiPAP) device with 
average volume-assured pressure support (AVAPS) and a back-up rate. Provided records do not document trial 
and failure of a bilevel positive airway pressure (BiPAP) device with AVAPS and a back-up rate. 
 
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 home ventilator (E0466) have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the home ventilator (E0466) . 
 
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.