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

 
We decided that the Plan does not have to waive the copayment for the ambulance service (A0428) provided 
on June 30, 2023. 
 
You asked the Plan to waive the copayment for the ambulance service (A0428). You say that the cost share is 
wrong The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 
copayment for ambulance services. 
 
You have been asked to pay a $90 copayment for the ambulance service (A0428). This item/service falls within 
the ambulance services benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the 
ambulance service (A0428) provided on June 30, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed. 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that this is the only bed you can sleep 
in. The Plan denied your request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the LTACH services are medically 
necessary. The Plan denied your request. The Plan says when the enrollee is ready to leave the current facility, 
they can receive the required services in a lower level of care. 
 
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 that it doesn't appear that the enrollee requires services that are not available at the 
facility being provided by the health Plan. In addition, the notes do not indicate that there is an expectation that 
they will require an additional inpatient stay that would meet or exceed 25 days. 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 LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pneumatic compressor and segmental pneumatic 
appliance to be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve pneumatic compressor and segmental pneumatic appliance. You say that the 
supplies should be covered. The Plan denied your request. The Plan says this is available in-network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
pneumatic compressor and segmental pneumatic appliance to be provided by an out-of-network (OON) 
provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bupivacaine (J3490) provided on August 28, 2023. 
 
You asked the Plan to pay for bupivacaine. You say that this drug was medically necessary and should be paid. 
The Plan denied your request. The Plan says this is a packaged service which is not paid separately. 
 
The Plan must follow Medicare rules. Medicare rules say that all services integral to accomplishing a procedure 
are considered bundled into that procedure and, therefore, are considered a component part of the 
comprehensive code.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of bupivacaine have not been met. Specifically, bupivacaine is a local anesthetic which would be 
considered integral to, and therefore included in the payment for the injection service or other procedure provided. Therefore, we decided that the Plan does not have to pay for bupivacaine (J3490) provided on August 
28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the urgent care visit (S9083) provided on 
July 02, 2023. 
 
You asked the Plan to waive the copayment for the urgent care visit (S9083). You say that there should not be 
any cost share. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $55 
copayment for urgently needed services. 
 
You have been asked to pay a $55 copayment for the urgent care visit (S9083). This item/service falls within 
the urgently needed services benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the urgent 
care visit (S9083) provided on July 02, 2023. 
 
Maximus read your letter and knows that you may have a quality of care concern. Maximus cannot address 
quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement 
Organization for further review.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gel-One 30mg/3ml syringe. 
 
You asked the Plan to pre-approve the drug. You say that this has been helpful in the past. The Plan denied 
your request. The Plan says this is not indicated for injecting into the shoulder. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found that the review has 
determined that the requested use of Gel-One is not FDA-approved for the enrollees diagnosis. Its use is not 
supported by one of the major drug compendia or by clinical research that appears in a Medicare-approved 
medical journal. The literature states that viscosupplementation therapy is medically necessary for the 
treatment of osteoarthritis in the knee. It is considered experimental and investigational for indications such as chondromalacia patellae, facet joint arthropathy, following anterior cruciate ligament reconstruction, 
meniscectomy, or partial or total knee arthroplasty; hemophilic arthropathy, muscle stiffness, spastic 
hemiparesis, osteochondritis dissecans, palendromic rheumatism, patellofemoral arthritis, patellofemoral 
syndrome (patellar knee pain), peripheral nerve pain, plantar nerve entrapment syndrome, psoriatic arthritis, or 
for use in joints other than the knee (e.g., ankle, carpo-metacarpal joint, elbow, hip, metatarso-phalangeal joint, 
shoulder, thumb, and temporomandibular joint) because the effectiveness of viscosupplementation for these 
indications has not been established. 
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gel-One 30mg/3ml syringe.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a microprocessor knee and rigid dressing for
the enrollee.

You asked the Plan to provide coverage for a microprocessor knee and rigid dressing. The Plan denied your
request. The Plan says the Medicare coverage criteria are not met. Maximus overturned the Plans denial. The
Plan requested a reopen and noted that the medical record documentation does not show why mechanical knee
will not meet enrollee's needs. A microprocessor knee, which is heavier, more prone to damage, water damage,
corrosion and requires daily charging, and makes kneeling more difficult would be more limiting to the
enrollee based on the enrollee's reported activity level of participating in 5Ks, hiking, skiing, horseback riding,
to various water sports. A microprocessor knee would be detrimental, rather than beneficial, in the activities
that the member wishes to perform.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that for Medicare to
consider coverage and payment for any item or service, the information submitted by the supplier or provider
must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare
coverage criteria have been met. We looked at the file and Medicare rules. Based on this information, we
decided that there is insufficient information in the record showing why the enrollee requires the requested
microprocessor knee. Therefore, we decided that the Plan does not have to provide coverage for a
microprocessor knee and rigid dressing for the enrollee.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electroencephalogram (EEG) during non-intracranial 
surgery (95955) provided on April 26, 2022. 
 
You asked the Plan to pay for the EEG during non-intracranial surgery. You say that these services were 
medically necessary, and you would like the claim to be reprocessed towards payment. The Plan denied your 
request. The Plan says the clinical value and effectiveness of an intraoperative EEG in the setting of T9 to T10 
thoracic laminectomy and discectomy surgery have not been demonstrated in the peer-reviewed literature. 
 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 EEG during non-intracranial surgery. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the provided medical records and review of the current peer-reviewed 
medical literature do not document that use of EEG has been shown in controlled studies in a Centers for 
Medicare & Medicaid Services (CMS) approved journal to result in sustained long term health benefits in 
patients undergoing thoracic spine surgery. 
 
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 EEG during non-intracranial surgery have not been met. Therefore, we 
decided that the Plan does not have to pay for the electroencephalogram (EEG) during non-intracranial surgery 
(95955) provided on April 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve expandable controller components for a wheelchair. 
 
You asked the Plan to pre-approve expandable controller. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says code K0108 should not be used for these components. 
 
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 expandable controller. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found no detailed records from the enrollee's treating physician are provided in this case to 
document the necessity of the requested components, particularly given the issues related to the codes used for 
the components. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of expandable controller have not been met. Therefore, we decided that the Plan 
does not have to pre-approve expandable controller components for a wheelchair.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 22 miles for a total of 72 miles. 
 
You asked the Plan to pre-approve the additional miles. You say that the additional miles are medically 
necessary for you to get to your appointments. The Plan denied your request. The Plan says the additional miles 
exceed the plans limit. 
 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 50 miles per one-way trip.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that your request would exceed the Plans mileage limit for routine transportation trips. Therefore, we decided 
that the Plan does not have to pre-approve an additional 22 miles for a total of 72 miles.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa (J7323). 
 
You asked the Plan to pre-approve Euflexxa. You say that you want to appeal the turn down of the gel 
injections Euflexxa for both knees. You also say that you have bone on bone in both knees, and you need these 
injections in order to walk. The Plan denied your request. The Plan says there was no documentation received 
from the provider that there has been significant improvement in pain and functional capacity achieved with the 
prior series of injections. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
 
 
 
 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 Euflexxa. Our reviewer says that this 
request is not medically necessary. Our physician reviewer found the record indicates that you have a diagnosis 
of osteoarthritis of the knee and have previously received viscosupplementation, completing a course in 
December 2022. The FDA has stated that the requested drug is indicated for the enrollee's condition. Our 
reviewer found that the record provided is insufficient to establish that the previous treatment was efficacious 
for the enrollee. The record provided does not establish the medical necessity and reasonableness, as defined by 
Medicare rules, of the requested service. Our physician reviewer also found that the elements of the coverage 
criteria are not satisfied, and the requested service cannot be 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa (J7323).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Durolane. You asked the Plan to pre-approve Durolane. 
You say that the requested drug is medically necessary. The Plan denied your request. The Plan says the 
information provided does not show that the enrollee has tried and failed or has a clinical reason not to use one of the preferred options: Synvisc-1 Monovisc, or that the enrollee has been using the requested medication in 
the past 12 months. 
 
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 Durolane. Our reviewer says that the 
requested drug is not medically necessary. Our physician reviewer found the Plan requires a trial of Synvisc 1 
or Monovisc before they will approve the requested drug. In this case, the enrollee has not tried and failed the 
required drug(s). There is no documentation indicating the Plan's required drug(s) 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 Durolane have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Durolane.   
 
Benefits for Durolane 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for an electronic connection, harness, and
expandable controller.

You asked the Plan to provide coverage for an electronic connection, harness, and expandable controller. The
Plan denied your request. The Plan says the Medicare criteria for these upgrades were not met. Maximus
overturned the Plans denial. The Plan requested a reopen and stated Maximus did not apply the correct criteria.
The Plan noted that the medical records show the enrollee has adequate upper extremity strength to operate the
standard switches that come with the approved power wheelchair.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that for Medicare to
consider coverage and payment for any item or service, the information submitted by the supplier or provider
must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare
coverage criteria have been met.

The available clinical documentation does not support that the requested upgraded electronics were medically
reasonable and necessary for the enrollee at the time of the appeal. Medicare coverage criteria were not met.
Therefore, we decided that the Plan does not have to provide coverage for an electronic connection, harness,
and expandable controller.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 9, 2023, to 
April 6, 2023. 
 
You asked the Plan to pay for the home health services as billed. You say that you have already submitted a 
NOA for this period of care. The Plan denied your request. The Plan says the claim has not been billed with the 
correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from March 9, 2023, to April 
6, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the automatic external defibrillator,with 
integrated electrocardiogram analysis, garment type (K0606) provided on June 17, 2023, to August 17, 2023. 
 
You asked the Plan to waive the coinsurance for the automatic external defibrillator,with integrated 
electrocardiogram analysis, garment type (K0606). You say that there should not be a cost share. The Plan 
denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Durable medical equipment (DME) and related supplies. 
 
You have been asked to pay 20% coinsurance for the automatic external defibrillator,with integrated 
electrocardiogram analysis, garment type (K0606). This item/service falls within the Durable medical equipment (DME) and related supplies benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance 
for the automatic external defibrillator,with integrated electrocardiogram analysis, garment type (K0606) 
provided on June 17, 2023, to August 17, 2023.