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

 
We decided that the Plan does not have to waive the copayment for the evaluation for a dual lead pacemaker 
system (93280) provided on March 15, 2023. 
 
You asked the Plan to waive the copayment for the evaluation for a dual lead pacemaker system (93280). 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 a $100 
copayment for Outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $100 copayment for the evaluation for a dual lead pacemaker system (93280). 
This item/service falls within the Outpatient diagnostic tests and therapeutic services and 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. However, since 
the allowed amount is less than the standard copayment, you only owe $90.50. Therefore, we decided that the 
Plan does not have to waive the copayment for the evaluation for a dual lead pacemaker system (93280) 
provided on March 15, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter (K0800). 
 
You asked the Plan to pre-approve a power scooter. You say that this is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the records do not show the use of a power operated vehicle 
(POV) will significantly improve the beneficiary's ability to participate in mobility related activities of daily 
living (MRADLs) and the enrollee will use it in the home. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 a power scooter. Our reviewer says that 
the requested power scooter is not medically necessary. Our physician reviewer found the provided records do 
not support the enrollee requires a power assisted scooter to perform self-care in the home. Therefore, the 
reviewer found that the requested power scooter is not medically reasonable or 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 a power scooter have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power scooter (K0800).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided by a chiropractor (99204) on August 
23, 2023. 
 
You asked the Plan to pay for the chiropractic services. You say that you have coverage for chiropractic 
services. The Plan denied your request. The Plan says this chiropractic service is excluded from coverage. 
 
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 the office visit provided by a chiropractor (99204) on August 23, 2023.
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 you prefer to admit to acute rehabilitation because 
you were independent before your hospitalization and you want to return to being independent. You say you 
are eager to participate in the three hours of aggressive rehabilitation that an acute rehabilitation hospital will 
offer you. The Plan denied your request. The Plan says you do not meet Medicare guidelines for services in an 
inpatient rehabilitation 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 complexity of your 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 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.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you need this level of care. The Plan denied your 
request. The Plan says your condition does not meet the criteria for an SNF admission. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ED services provided on July 11, 2022. 
 
You asked the Plan to pay for the ED services. You say that this should be covered. The Plan denied your 
request. The Plan says Medicare payment cannot be made to this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare. 
However, during the COVID-19-PHE, such providers were allowed to enroll as temporary hospitals and could 
be paid for services during this period.  
We looked at the file and Medicare rules. We find that the provider at issue has not enrolled as a temporary 
hospital as allowed during the PHE. As such, this provider is not eligible for Medicare payment. Therefore, we 
decided that the Plan does not have to pay for the ED services provided on July 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle kit sensor. 
You asked the Plan to pre-approve the FreeStyle kit sensor. You say that the medical records provided support 
the need for the requested CGM.  The Plan denied your request. The Plan says the enrollee does not meet 
Medicare criteria.  
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the FreeStyle kit sensor. Our reviewer 
says that this item is not medically necessary. Our physician reviewer found coverage criteria for CGM require 
low blood glucose sugar or insulin use. Although the CGM indicates (by a check mark) that the enrollee is 
taking insulin, the notes submitted do not corroborate this. Rather, the office note from December 27, 2023 
indicates that the enrollee takes Metformin and Trulicity which are medications that usually do not cause low 
blood glucose sugar. We are not told of any low blood glucose sugar. Criteria are not met for CGM 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 FreeStyle kit sensor have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a FreeStyle kit sensor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro Motion G device (L8702). 
 
You asked the Plan to pre-approve a MyoPro Motion G device. You say that the services are necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
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 a MyoPro Motion G device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the Myopro orthosis depends upon the presence of a minimal level of 
electrical activity in the impacted arm, some active motion capacity in the shoulder and absence of increased 
tone in the hands and fingers to have minimal impact on self-care. The device does not have reliable impact on self-care when the stroke is more than a year old. Users of the device have not been shown to experience 
significant impact on self-care including bathing, dressing, toileting or eating. The American Heart Association 
has recommended the device as a means to enhance therapy but not as support for self-care. Per SSA 1862 
(a)1(A) as the device is not medically necessary, not the standard of care and not as effective as standard 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 a MyoPro Motion G device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a MyoPro Motion G device (L8702).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the LTACH admission is the appropriate 
level of care. The Plan denied your request. The Plan says the enrollee does not meet the criteria for the 
LTACH admission. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was admitted with acute hypoxic and hypercapnic respiratory failure due 
to inhalation injury.  The record indicates that the enrollee has ongoing acute medical issues and still requires 
acute care services.  The enrollee continues to receive acute care services, and these have not been denied.  The 
medical record does not indicate that the enrollee requires services that they are not currently receiving but that 
would be available at the LTACH facility.  The elements of the coverage rules are not satisfied.  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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple power 
options (tilt/recline, legrests), and accessories. 
 
You asked the Plan to pre-approve a Group 3 power wheelchair with multiple power options. You say that this 
is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not have 
a medical need for the requested multiple power options. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair with multiple power 
options may be covered when certain criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a Group 3 power wheelchair with 
multiple power options. Our reviewer says that the requested Group 3 power wheelchair is not medically 
necessary. Our physician reviewer found the provided documentation does not support that the enrollee is high 
risk for skin breakdown, uses a catheter intermittently, has spasticity or requires an alternative means of 
managing power drive. Therefore, the reviewer found that the requested Group 3 power wheelchair with 
multiple power options is not medically reasonable or 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 a Group 3 power wheelchair with multiple power options have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple 
power options (tilt/recline, legrests), and accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for out of network urgent care services provided on March 17, 2023,
under code S9088.

You asked the Plan to pay for these services. The Plan denied your request. The Plan says the services billed,
code S9088 are not covered by Medicare. Maximus overturned the Plans denial. The Plan requested a reopen
and stated that Maximus did not apply the correct billing criteria. The Plan noted that while the Plan provided
coverage for the urgent care visit claim, but the Plan denied code S9088 as it is not a code covered by
Medicare. The Plan noted you have Medicaid benefits managed by an external carrier and the services in
appeal may be coverable under your Medicaid benefits.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. Providers must report services with the appropriate code. Code S9088 has a status
indicator that prevents payment when billed to Medicare enrollees. In this case you sought out of network care
from a provider who is billing the Plan for a code that is not covered by Medicare. As the provider is not in
network, the Plan cannot compel the provider to correct this claim. Therefore, we decided that the Plan does
not have to pay for out of network urgent care services provided on March 17, 2023, under code S9088.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gamunex. 
 
You asked the Plan to pre-approve Gamunex. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the requested drug is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Gamunex. Our reviewer says that the 
requested drug is not medically necessary. Our physician reviewer found there is no documentation that 
Gamunex meets all Medicare criteria for medically reasonable and necessary for the enrollee. Provided records 
do not clarify severe polysaccharide nonresponsiveness as required by the LCD. There is no documentation 
that the enrollee meets the criteria for the safe and effective use of Gamunex. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gamunex have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gamunex.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the esophagoscopy provided on February
14, 2023, and the specialist office visits, and x-ray provided on April 24, 2023.

You asked the Plan to waive the this cost share. You say that you do not believe this cost share is correct. The
Plan denied your request. The Plan says this cost sharing was charged correctly. Maximus overturned the Plans
denial because a Plan contract was not submitted with the case file. The Plan requested a reopen and submitted
the required contract information.

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 cost
share for each service provided. You have been asked to pay the correct amounts for each service 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 cost share for the esophagoscopy
provided on February 14, 2023, and the specialist office visits, and x-ray provided on April 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on February 13, 2023, billed 
with procedure code 88305. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the claim was billed with an inappropriate 
diagnosis code. 
 
The Plan must follow Medicare rules. Medicare rules say that some ICD-10-CM codes indicate laterality, 
specifying whether the condition occurs on the left, right or is bilateral. If the side is not identified in the 
medical record, assign the code for the unspecified side.  
We looked at the file and Medicare rules. We find that the claim was not reported to the highest level of 
specificity as it is not appropriate to report an unspecified diagnosis when a more appropriate code is available. 
Based on this information, we decided that Medicare rules for coverage of the practitioner services provided 
have not been met. Therefore, we decided that the Plan does not have to pay for practitioner services provided 
on February 13, 2023, billed with procedure code 88305.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat elevator (E2300), power standing (E2310), lateral 
thigh/knee support (E0953), and tray (E0950). 
 
You asked the Plan to pre-approve the wheelchair accessories. You say that the seat elevator is supposed to be 
covered. The Plan denied your request. The Plan says the power seat elevation, power standing, and tray are 
not considered primarily medical in nature. The Plan says that the lateral thigh/knee supports are used in 
conjunction with the power standing feature. The Plan also says that since the power standing feature is not 
medically necessary, neither is the lateral support. 
 
The Plan follows Medicare rules. Medicare rules say that power seat elevation equipment is reasonable and 
necessary for individuals using complex rehabilitative power-driven wheelchairs when certain criteria are met. 
The rules say that for equipment to be covered, it must primarily serve a medical purpose.   
 
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 wheelchair accessories. Our 
reviewer says that the requested seat elevator is not medically necessary. Our physician reviewer found the 
provided documentation does not support that the enrollee has undergone a specialty evaluation that confirms 
the enrollees ability to safely operate the seat elevation equipment in the home. Therefore, the reviewer found 
that the requested seat elevator for a power wheelchair is not medically reasonable or 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 wheelchair accessories have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a seat elevator (E2300), power standing (E2310), lateral thigh/knee support 
(E0953), and tray (E0950).