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

We decided that the Plan does not have to pre-approve Imfinzi.

You asked the Plan to pre-approve Imfinzi. The Plan denied your request. The Plan says this is not medically necessary.

The Plan must follow Medicare rules. The rules say that Imfinzi is covered for the indication established in the applicable LCD.

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 Imfinzi. Our reviewer says that Imfinzi is not medically reasonable and necessary in this case. Our physician reviewer found that based on the medical records provided and the Medicare-approved major drug compendia, there is no documentation that the Imfinzi at issue in this case meets all Medicare/LCD (L37205) criteria. The Medicare-approved major drug compendia only support the use of Imfinzi for unresectable stage 3 non-small cell lung cancer after concurrent radiation therapy with platinum-based chemotherapy. The National Comprehensive Cancer Network only supports Imfinzi in this scenario after therapy with tremelimumab. The records document the enrollee is stage 4 and the records do not document the enrollee had treatment with tremelimumab.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Imfinzi have not been met. Therefore, we decided that the Plan does not have to pre-approve Imfinzi.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intermittent urinary catheter to be provided by an out-
of-network (OON) provider.  
 
You asked the Plan to pre-approve intermittent urinary catheter to be provided by an OON provider. You say 
that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that 
are able to provide these services. Therefore, coverage criteria have not been met. 

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 
intermittent urinary catheter to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311), expandable controller 
harness (E2313), and expandable controller (E2377). 
 
You asked the Plan to pre-approve an electronic connection, expandable controller harness, and expandable 
controller. You say that you are appealing on the grounds that Medicare has reviewed and approved the 
request, and found the services to be both medically necessary and covered under Medicare guidelines. The 
Plan denied your request. The Plan says although there are three approved power options on this wheelchair 
(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 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 an electronic connection, expandable 
controller harness, and expandable controller. Our reviewer says that the requested items/services are not 
considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has 
advanced MS and is non -ambulatory. The enrollee is able to feed and groom themself. Our reviewer also 
found that the enrollee has adequate strength to manage standard power drives. 
 
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, expandable controller harness, and expandable 
controller have not been met. Therefore, we decided that the Plan does not have to pre-approve an electronic 
connection (E2311), expandable controller harness (E2313), and expandable controller (E2377).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Mastergraft allograft (20930) and a bone marrow 
aspirate (20939). 
   
You asked the Plan to pre-approve Mastergraft allograft and a bone marrow aspirate. You say that this is 
medically necessary. The Plan denied your request. The Plan says The clinical value and effectiveness of the 
Medtronic Mastergraft Allograft in the setting of thoracolumbar laminectomy and spinal fusion surgery has not 
been demonstrated in the peer-reviewed literature. The clinical value and effectiveness of bone marrow aspirate 
in the setting of spinal fusion 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 pre-approve Mastergraft allograft and a bone 
marrow aspirate. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found Mastergraft allograft and bone marrow aspirate are 
experimental for use as bone graft. Iliac crest autogenous bone graft is the gold standard. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Mastergraft allograft and a bone marrow aspirate have not been met. Therefore, 
we decided that the Plan does not have to pre-approve Mastergraft allograft (20930) and a bone marrow 
aspirate (20939).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for 200 additional units of Botox for the enrollee.

You asked the Plan to provide coverage for 200 additional units of Botox. You say that this treatment is
medically necessary. The Plan denied your request. The Plan says while 100 units were approved, the
recommended dosing criteria are not met with the addition of 200 additional units. Maximus overturned the
Plans denial. The Plan requested a reopen and stated that Maximus agreed with the Plan in the review yet
applied the incorrect criteria and issued a favorable decision.

The Plan is correct. The Plan must follow Medicare rules. Medicare has specific coverage criteria for Botox.
Our reviewer stated the current FDA guidelines for the use of Botox for the treatment of neurogenic detrusor
overactivity (NDO) state although many clinicians have until now routinely used a 300-unit Botox dose in
catheter dependent NDO patients, recent data suggests no significant benefit to the higher dosing,
supporting the FDA guidelines. We looked at this physician's review, the file, and Medicare rules. Based on
this information, we decided that Medicare rules for coverage of 200 additional units have not been met.
Therefore, we decided that the Plan does not have to provide coverage for 200 additional units of Botox for the
enrollee, making the total dosage 300 units.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the T8 kyphoplasty. 
 
You asked the Plan to pre-approve the T8 kyphoplasty. You say that the enrollee has a chronic burst fracture 
with retropulsion that has developed into a non-union. You say this condition, by definition, is chronic.  The 
Plan denied your request. The Plan says the T8 kyphoplasty is not medically necessary. The Plan says the T8 
compression fracture is neither acute not sub-acute at this point.  
 
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 T8 kyphoplasty. Our reviewer says 
that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee was being treated for an unstable burst fracture of unspecified thoracic level. The 
enrollee presented with neck pain and cervical radiculopathy, thoracic back pain with thoracic radiculopathy, 
and back pain with lumbar radiculopathy. However, the documentation does not show an acute or sub-acute 
fracture at T8. Additionally, there is no documentation of a progression of the body height loss, greater than 
25% vertebral body height loss, kyphotic deformity, or a severe impact on daily activities. Therefore, the 
enrollee does not meet the criteria for kyphoplasty. 
 
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 T8 kyphoplasty have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the T8 kyphoplasty.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service October 13, 
2022. 
 
You asked the Plan to pay for procedure code 99053. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says procedure code 99053 is considered bundled and 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 procedure code. 
 
We find that procedure code 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99053 billed for date of service October 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 billed for date of service March 10, 
2022.  
 
You asked the Plan to pay for procedure code 99285. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 99285 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 99285 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 99285 billed for date of service March 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a Group 3 power wheelchair with multiple
power options for the enrollee.

You asked the Plan to provide coverage for a Group 3 power wheelchair with multiple power options. You say
that the requested power wheelchair is medically necessary. The Plan denied your request. The Plan says the
Medicare coverage criteria for a Group 3 power wheelchair and upgraded options are not met. Maximus
overturned the Plans denial. The Plan requested a reopen and stated that Maximus reviewed a Group 2 power
wheelchair and accessories in error.

The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that a Group 3 power
wheelchair can be covered only for enrollees who have a mobility limitation that is due to: 1. A neurological
condition; 2. Myopathy; or 3. Congenital skeletal deformity.

The medical records do not show that the enrollee has a mobility limitation that is due to a neurological
condition, myopathy, or congenital skeletal deformity. Therefore, we decided that the Plan does not have to
provide coverage for a Group 3 power wheelchair with multiple power options for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an MRI and periprocedural device evaluation and 
programming on March 10, 2023.  
 
You asked the Plan to pay for an MRI and periprocedural device evaluation and programming. You say that 
you were told the facility would be in-network and you would not have gone there if you had known they were 
out-of-network. The Plan denied your request. The Plan says you must generally receive your care from a 
network provider. 
 
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, 
plans are not required to make payments for any services received by enrollees that are not provided directly by 
the Plan or through arrangements made by the Plan. 
 
The services at issue in this appeal were not provided in an emergency or urgent care situation. These services 
were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not 
have to pay for an MRI and periprocedural device evaluation and programming on March 10, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0675) provided on 
April 18, 2023, through May 8, 2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that the item was medically 
necessary. The Plan denied your request. The Plan says the item was not medically necessary. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for the pneumatic compression device (E0675) provided on April 18, 2023, through May 8, 2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for localized delivery of antimicrobial agent/per tooth (D4381) provided on 
June 20, 2023. 
 
You asked the Plan to pay for localized delivery of antimicrobial agent/per tooth. You say that you thought this 
would be covered. The Plan denied your request. The Plan says that this is not payable when done on the same 
day as a prophylaxis or periodontal scaling and root planing. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for this service by a contract provider. The file does not show that the Plan provided notice 
that localized delivery of antimicrobial agent/per tooth would not be covered. Under Medicare rules, this means 
localized delivery of antimicrobial agent/per tooth is considered approved by the Plan. Therefore, we decided 
that the Plan has to pay for localized delivery of antimicrobial agent/per tooth (D4381) provided on June 20, 
2023.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each podiatry visit provided on January 05, 
2023, to March 14, 2023. 
 
You asked the Plan to waive the copayment for each podiatry visit. You say that these services should be fully 
covered. 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 $15 
copayment for podiatry services. 
 
You have been asked to pay a $15 copayment for each podiatry visit. This item/service falls within the podiatry 
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. The total amount you owe is $90 ($15 copayment x 6 visits = $90). Therefore, we decided that the Plan 
does not have to waive the copayment for each podiatry visit provided on January 05, 2023, to March 14, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable


We decided that the Plan does not have to provide coverage for a Group 3 power wheelchair with an
expandable controller (E2377), harness (E2313), and electrical connection (E2311).

You asked the Plan to provide coverage for an expandable controller (E2377), harness (E2313), and electrical
connection (E2311). The Plan denied your request. The Plan says the Medicare criteria for these accessories
were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did
not apply the correct criteria. The Plan noted that the medical records show you have a three out of five
bilateral arm strength, and you show to be independent with activities such as feeding, meal preparation, and
grooming. The records show you have adequate strength to use the general switches included with the
approved power wheelchair.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare has specific coverage criteria
for the approval of the requested upgraded electronics. The medical records provided do not show that the
upgraded electronics are medically necessary, nor do they state you are unable to use the standard switches
provided with the requested power wheelchair. Medicare coverage criteria are not met. Therefore, we decided
that the Plan does not have to provide coverage for a Group 3 power wheelchair with an expandable controller
(E2377), harness (E2313), and electrical connection (E2311).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the orthosis, coded L3960, billed for date of service May 31, 
2023. 
 
You asked the Plan to pay for the billed service. You say that medical records were provided. The Plan denied 
your request. The Plan says the documentation does not support the billed service. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. The records do not show that an orthosis was part of the enrollees treatment plan. The records do 
not show that the enrollee was being treated for a condition that would require an orthosis.Therefore, we 
decided that the Plan does not have to pay for the orthosis, coded L3960, billed for date of service May 31, 
2023.
Appeal type: Imaging
Decision: Unfavorable

We decided the Plan does not have to pay for codes R0070 and Q0082 for date of service October 29, 2022.

You asked the Plan to pay for these services. The Plan denied your request. The Plan says the Medicare billing
criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and noted that
Maximus did not apply the correct billing criteria. The Plan notes that codes R0070 and Q0082 for date of
service October 29, 2022, due to an error with the POS code. The claim should have been billed with POS code
32 for a non-covered nursing facility stay.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly.

In this case, this claim could not be paid as billed due to an error with the POS code reported. Medicare rules
for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for
codes R0070 and Q0082 for date of service October 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acupuncture services to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve acupuncture services. You say that you cannot drive long distances which is 
why you are going to the closet provider available. The Plan denied your request. The Plan says that 
acupuncture services are 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 
acupuncture services to be provided by an out-of-network (OON) provider.