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

 
We decided that the Plan does not have to pre-approve  the parenteral nutrition (B4185, B4189, B4193, B4197, 
B4199, B4224). 
 
You asked the Plan to pre-approve  the parenteral nutrition. You say that Intradialytic Parenteral Nutrition 
(IDPN) therapy provides a safe, effective, and less costly intermediate treatment to bridge the gap between first line treatments and the more aggressive interventions.  The Plan denied your request. The Plan says nutrition 
through the vein is not supported when the enrollee's body is able to get nutrition through their bowels. 
 
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 parenteral nutrition. Our physician 
reviewer found it is documented that enteral nutrition has been considered and ruled out, tried and been found 
ineffective. The enrollee does not have a condition involving the small intestine and/or its exocrine glands 
which significantly impairs the absorption of nutrients. The enrollee does not have a disease of the stomach 
and/or intestine which is a motility disorder and impairs the ability of nutrients to be transported through and 
absorbed by the gastrointestinal (GI) system. The enrollee does not have a permanent impairment. The enrollee 
does not meet the LCD criteria for coverage. 
 
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 parenteral nutrition have not been met. Therefore, we decided that the Plan 
does not have to pre-approve  the parenteral nutrition (B4185, B4189, B4193, B4197, B4199, B4224).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says admission to the IRF is not medically necessary.  
 
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 that 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. While the enrollee may have a need for physical 
therapy 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 
the 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 an IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on December 3, 2022, billed 
with codes 81227, 81231, 81232, 81306 and 81335. 
 
You asked the Plan to pay for the genetic testing billed. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says panel testing should be billed using one CPT 
code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
December 3, 2022, billed with codes 81227, 81231, 81232, 81306 and 81335.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87640 billed for date of service June 6, 2022. 
 
You asked the Plan to pay for procedure code 87640. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says payment for code 87640 is bundled into 
payment for code 87641. 
 
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 87640 
is a column II code to column I code 87641. 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 code 87640 billed for date of service June 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the addition to an approved prosthesis for an alignable system (L5910).

You asked the Plan to pre-approve the prosthetic addition L5910. You say that the requested items should be approved. The Plan denied your request. The Plan says code L5910 cannot be approved as it is not compatible with the base code L5540. Since the base code is for a non-alignable system, the alignable system code is not appropriate.

Please note: Maximus reviewed the Plan's denial rationale and finds that it is not appropriate. All prosthesis base codes are for non-alignable systems and inclusion of code L5910 is to denote an alignable system. As such, we based our decision on medical necessity of the addition.

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 prosthetic addition L5910. Our reviewer says that the requested item (L5910) is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is a 61-year-old man who previously underwent a right below knee amputation. On March 15, 2023, it is documented that the enrollee was progressing as expected. A Prosthesis Amendment notes that the enrollee will be able to ambulate as a functional level to limited community ambulator with the below knee prosthesis. The clinical information available in the case file does not support that an alignable system is medically reasonable and necessary for the enrollee 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 prosthetic addition L5910 have not been met. Therefore, we decided that the Plan does not have to pre-approve the addition to an approved prosthesis for an alignable system (L5910).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a microprocessor control feature (L5856), a stance 
phase control (L5828), a stance flexion feature (L5845), and a dampening feature (L5848).  
 
You asked the Plan to pre-approve the prosthetic features. You say that the requested items are medically 
necessary. The Plan denied your request. The Plan says that the prosthetic features 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 the prosthetic features. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there is no information provided indicating that you require an advanced 
microprocessor knee to meet your ambulation capacity. You are presently a K2 ambulator. 
 
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 prosthetic features have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a microprocessor control feature (L5856), a stance phase control (L5828), a 
stance flexion feature (L5845), and a dampening feature (L5848).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a temporary crown (code D2799) for tooth #7, 8, 9, and 10. 
 
You asked the Plan to pre-approve the temporary crowns. You say that you are having extreme sensitivity due 
to your teeth being unprotected. The Plan denied your request. The Plan says that the temporary crown is 
included with the permanent crown. 
 
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. The Plan covers the crown 
when the services are medically necessary and reasonable. 
 
In this case, the EOC does not clearly state that temporary crowns are to be included in the payment for the 
permanent crown. The EOC simply states that crowns are covered, without noting any additional limitations to 
coverage. Further, the Plans internal coverage guidelines list D2799 as an applicable code. The Plans internal 
coverage guidelines also say that temporary restorations are generally considered inclusive to the crown 
procedure; however, the Plan does not clearly say in which circumstances a temporary crown would and would 
not be inclusive. Therefore, we decided that the Plan has to pre-approve a temporary crown (code D2799) for 
tooth #7, 8, 9, and 10.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI).  
 
You asked the Plan to pre-approve SSBCI benefits. You say that you should have this benefit. The Plan denied 
your request. The Plan says the criteria for eligibility have not been met.  
 
The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.   
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an 
eligible condition that meets all the required criteria. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).
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 the enrollee needs inpatient rehabilitation to be able 
to gain strength and be able to function on a day to day basis. The Plan denied your request. The Plan says the 
enrollee does not meet the Medicare criteria for admission to an IRF.  
 
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 do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic service provided on December 7, 2022. 
 
You asked the Plan to pay for chiropractic service. You say that it is medically necessary. The Plan denied your 
request. The Plan says this service is not covered by Medicare when performed by a chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for chiropractic service provided on December 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 3 system (A4239). 
 
You asked the Plan to pre-approve a FreeStyle Libre 3 system. You say that you feel this is the most 
appropriate treatment for the enrollee's Type 2 diabetes mellitus with other kidney complication. The Plan 
denied your request. The Plan says the Freestyle Libre 3 system is only compatible with certain smart devices 
and is not used with a stand-alone receiver or insulin infusion pump classified as Durable Medical Equipment 
(DME) to display CGM glucose data. The Pan also says that this item is not covered by Medicare. 
 The Plan must follow Medicare rules. Medicare rules say that a non-adjunctive continuous glucose monitor 
(CGM) must be billed with code E2103. The rules also say that only devices reviewed by the PDAC and 
assigned code E2103 may be billed using this code.  
 
We looked at the file and Medicare rules. The request at issue is for the Freestyle Libre 3 non-adjunctive CGM. 
However, this device has not been reviewed by the PDAC and has not been assigned code E2103. As such, this 
non-adjunctive CGM device is not eligible for coverage at this time. Therefore, we decided that the Plan does 
not have to pre-approve a FreeStyle Libre 3 system (A4239).
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  the service is medically necessary. The Plan denied 
your request. The Plan says the IRF care is not medically necessary, and the enrollee's needs can be met at a 
lower level of care such as a skilled nursing facility. 
 
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 enrollee was admitted for weakness and hyperglycemia. The enrollee's medical 
problems are stable, and there are no complex nursing or rehabilitation needs. The enrollee does 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. 
 
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 below knee alignment system (L5910), an axial 
rotation unit (L5984), and a shank foot system with vertical loading pylon (L5987). 
 
You asked the Plan to pre-approve the shank foot system and alignment system. You say that your current leg 
is causing sores and you are unable to use it. The Plan denied your request. The Plan says that your current foot 
is still under warranty and your alignment system is undamaged. 
 
The Plan must follow Medicare rules. Medicare rules say that durable medical equipment is not covered if less 
than five years old and undamaged. 
 
The record shows your current alignment system has no evidence of damage. The records also shows that your 
current foot is only three years old. Therefore, we decided that the Plan does not have to pre-approve a below 
knee alignment system (L5910), an axial rotation unit (L5984), and a shank foot system with vertical loading 
pylon (L5987).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional trips. You say that you have no transportation for your 
appointments. The Plan denied your request. The Plan says your benefit only allows sixty trips for this service. 
 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 60 one-way trips per year.  
 
The file shows that 40 additional trips were requested. We looked at your request, the records in the case file, 
and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for 
coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional 
routine transportation.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is at high risk for falls, injury, and re-
admission to acute care. You would like reconsideration based on the records submitted. The Plan denied your 
request. The Plan says the IRF services requested do not meet the requirements for approval.  
 
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 that the complexity of the enrollees 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. While the enrollee may have a need for physical 
therapy 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 
the 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 an IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the grip black foam (K0108) Tru Balance 3 Base 
mounted lights (K0108). 
 
You asked the Plan to pre-approve the wheelchair accessories. You say that please review the attached medical 
documentation to support the need of the custom medical equipment being requested for the enrollee. The Plan 
denied your request. The Plan says the light kit and grip foam do not serve a medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.    

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Therefore, we 
decided that the Plan does not have to pre-approve the grip black foam (K0108) Tru Balance 3 Base mounted 
lights (K0108).