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

 
We decided that the Plan does not have to pre-approve a Q6 Edge Stretto (E1399), electronic connection 
(E2311), harness (E2313), expandable controller (E2377), joystick (K0108), footplates (K0108), and seat belt 
(E0978). 
 
You asked the Plan to pre-approve a Q6 Edge Stretto and additional items and accessories. You say that the 
enrollee's current wheelchair does not fit because it is too small and is causing them to have pain on both sides 
of their body while in use. You also say that the enrollee uses the wheelchair full time to move around the 
house. The Plan denied your request. The Plan says code E1399 does not match the power wheelchair 
requested, as required by Medicare guidelines. The electronic connection, harness, and expandable controller 
cannot be covered as it is not medically necessary to control the three requested power options through the 
joystick (drive interface). The Plan says that the joystick is unbundled from the expandable controller and 
harness. The footplates are miscoded and represent duplicate services. The Plan also says that the seat belt is 
unbundled from the power wheelchair. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules also say that if a PWC base is 
not covered, then related accessories will be denied. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a Q6 Edge Stretto and additional items and accessories have not been met. In this case, the CPT 
Code Manual definition of code E1399 is Durable medical equipment, miscellaneous. We find that CPT code 
E1399 is not appropriately being used to represent the Q6 Edge Stretto PWC base that is being requested. We 
reviewed the Pricing Data Analysis and Coding (PDAC) Product Classification List and found that this specific 
device should be coded using K0861. Since the requested E1399 code is not covered for the requested PWC 
base, the related accessories in dispute are also not covered.  Therefore, we decided that the Plan does not have 
to pre-approve a Q6 Edge Stretto (E1399), electronic connection (E2311), harness (E2313), expandable 
controller (E2377), joystick (K0108), footplates (K0108), and seat belt (E0978).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided from May 7, 2023, to 
May 10, 2023. 
 
You asked the Plan to pay for the medications. You say that they said they told the enrollee they might have to 
pay for the self-administered drugs, but the enrollee does not remember things and would not know what they 
were talking about. You also say that the enrollee does not handle their medications on their own, but the 
medications are given to them when it is time for them. The Plan denied your request. The Plan says the 
medication is not covered as a medical benefit under the Plan.  
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
provided from May 7, 2023, to May 10, 2023.  
 
Benefits for the medications 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 pre-approve a shower or bath chair.  
 
You asked the Plan to pre-approve a shower chair. You say that you would like reconsideration because the 
requested shower or bath chair is medically necessary. The Plan denied your request. The Plan says this item is 
not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower or bath chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 power wheelchair with captain's chair, up to 
300 pounds (K0823) and accessories.  
 
You asked the Plan to pre-approve the Group 2 power wheelchair. You say that this is medically necessary for 
the enrollee. The Plan denied your request. The Plan says the requested power wheelchair is not medically 
necessary. 
 
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 the Group 2 power wheelchair. Our 
reviewer says that the requested Group 2 power wheelchair is not medically necessary. Our physician reviewer 
found the provided documentation indicates the enrollee is modified independent with mobility and can use a 
walker for assistance with ambulation in the home to reduce risk of falling. The reviewer found that the 
enrollee was evaluated by physical therapy and noted to have 4/5 motor strength in the upper and lower 
extremities and be modified independent with mobility, transfers and negotiating stairs. Therefore, the reviewer 
found that the requested Group 2 power wheelchair and accessories are not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Group 2 power wheelchair have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a Group 2 power wheelchair with captain's chair, up to 300 pounds 
(K0823) and accessories.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided the Plan does not have to waive the cost share for a home ventilator provided on February 2, 2023.

You asked the Plan to waive this cost share. You say that you were told you would be paying $5 per month.
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 file. The Plan requested a reopen and
submitted the required contract.

The Plan is correct in this case. 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 20% coinsurance this type of equipment. Review of the file shows that you
received a home ventilator on February 2, 2023. You have been asked to pay a 20% coinsurance for these
services, for a total of $211.05.

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 cost share for a the home ventilator provided on February 2, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on May 18, 2023, by an out-
of-network (OON) provider.  
 
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 services were provided by an out of network 
provider. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for practitioner services provided on May 18, 2023, 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel provided on June 13, 2023, billed with 
codes 87150, 87486, 87496, 87498, 87502, 87503, 87532, 87541, 87581, 87634, 87635 and 87801. 
 
You asked the Plan to pay for the laboratory panel billed. You say that this testing was necessary and is 
supported in the medical record. 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 a 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 a laboratory 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 laboratory 
panel billed have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory 
panel provided on June 13, 2023, billed with codes 87150, 87486, 87496, 87498, 87502, 87503, 87532, 87541, 
87581, 87634, 87635 and 87801.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Hematology Profile Plus panel (81455, 81456) provided 
on June 5, 2023. 
 You asked the Plan to pay for the Hematology Profile Plus panel. You say that this testing was medically 
necessary. The Plan denied your request. The Plan says screening services are not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the Hematology Profile Plus panel, was requested solely for screening purposes. 
Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not 
have to pay for the Hematology Profile Plus panel (81455, 81456) provided on June 5, 2023.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the infectious agent detection by nucleic acid for Neisseria gonorrhoeae
provided on March 1, 2023, billed with codes 87591 and 87491.

You asked the Plan to pay for codes 87591 and 87491. The Plan denied your request. The Plan says that all
codes were approved aside from codes 87591 and 87491. The Plan states these codes were denied because they
are not covered by Medicare.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information
regarding their decision to deny your request. The Plan has not provided a valid denial rationale in this case. It
is noted that this code was denied because the panel is not covered. However, the Plan determined that payment
should be made for the 9 other codes billed on this claim. No rationale for denying this specific code out of the
10 billed was provided. The records clearly show that this pathogen was tested as part of this panel. Therefore,
we decided that the Plan has to pay for the infectious agent detection by nucleic acid for Neisseria gonorrhoeae
provided on March 1, 2023, billed with code 87591 and 87491.

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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF)
admission and services.

You asked the Plan to provide coverage for IRF care. You say that at the time of the appeal, IRF admission was
necessary. The Plan denied your request. The Plan says the required Medicare criteria were not met. Maximus
overturned the Plans denial stating due to the enrollee's fragile state, an IRF admission would be beneficial.
The Plan requested a reopen and stated that Maximus did not apply the correct criteria. The Plan noted the
medical records are clear that the enrollee would not be able to fully participate in an IRF therapy program
because of their fragile state and current medical conditions.

The Plan is correct in this case. 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.
The enrollee must have the ability to actively participate in and to benefit from an intensive rehabilitation
therapy program. This intensive rehabilitation therapy program generally consists of at least three hours of
therapy per day at least five days per week. Based on the medical records provided, the enrollee did not meet
these criteria at the time of the appeal. Therefore, we decided that the Plan does not have to provide coverage
for acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the refractive exam billed with code 92015 for December 6,
2022, to December 16, 2022.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services are not covered. Maximus overturned the Plans denial. The Plan requested a
reopen and noted that Maximus did not apply the correct contract criteria.

The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that Medicare does not
cover routine vision services and eyewear. The services you asked the Plan to pay for are considered routine
vision services or eyewear. Therefore, we decided that the Plan does not have to pay for the refractive exam
billed with code 92015 for December 6, 2022, to December 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on April 25, 2023. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for the lab services provided on April 25, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a microprocessor knee (L5852, L5845,
L5848, L5856).

You asked the Plan to provide coverage for a microprocessor knee. The Plan denied your request. The Plan
says the medical records provided by the physician are inconsistent with the statements made by the prosthetist.
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 documentation does not show why a mechanical knee cannot be used
for the enrollee's prosthesis. The enrollee's physician documents the enrollee has the potential to be a K3
ambulator and there is no documentation presented as to why a microprocessor knee is medically necessary for
the enrollee.

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 to determine if Medicare rules for coverage of this
equipment have been met. Therefore, we decided that the Plan does not have to provide coverage for a
microprocessor knee (L5852, L5845, L5848, L5856).
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 for the enrollee.

You asked the Plan to pre-approve IRF care. You say that the medical records support the need for IRF
admission. The Plan denied your request. The Plan says that the enrollee does not meet the Medicare criteria
for admission to an IRF.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for IRF care. Our
Medical Director states that clinical documentation does not support that the complexity of the enrollee's
nursing, medical and rehabilitation needs required an acute hospital inpatient stay with an interdisciplinary
approach to rehabilitation care. Our Medical Director found that the enrollee's condition does not meet
Medicare criteria for IRF 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 for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab panel provided on January 5, 2023. 
 
You asked the Plan to pay for the panel. The Plan denied your request. The Plan says there is a more 
appropriate code for the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that if a laboratory procedure produces multiple 
reportable test results, only a single HCPCS/CPT code shall be reported for the procedure. 
 
We looked at the file and Medicare rules. The testing in this case was billed with multiple codes and not one 
code as required by Medicare rules. Based on this information, we decided that Medicare rules for coverage of 
the panel have not been met. Therefore, we decided that the Plan does not have to pay for the lab panel 
provided on January 5, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ultralight weight manual wheelchair. 
 
You asked the Plan to pre-approve an ultralight weight manual wheelchair. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the requested device is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that an ultralight weight wheelchair is only covered for 
certain indications. 
 
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 ultralight weight manual wheelchair. 
Our reviewer says that the documentation does not support that the requested item is medically reasonable or 
necessary. Our physician reviewer found the enrollee has severe osteoarthritis with chronic pain. The 
documentation does not support that the patient requires individualized fitting and adjustments for one or more 
features such as, but not limited to, axle configuration, wheel camber, or seat and back angles, which cannot be 
accommodated by a K0001 through K0004 manual wheelchair. Therefore, the enrollee does not meet criteria 
for the requested device. 
 
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 ultralight weight manual wheelchair have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an ultralight weight manual wheelchair.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia.  
You asked the Plan to pre-approve Prolia. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
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 Prolia. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has osteoporosis. The documentation does not support that the enrollee has had either a 
history of osteoporosis-related fracture or has tried and failed zoledronic acid. The documentation does not 
support that zoledronic acid would likely be less effective and/or likely have adverse effects for the enrollee. 
Therefore, the enrollee does not meet criteria for the requested drug.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 29540-LT and 29540-RT billed for date of 
service July 5, 2023.  
 You asked the Plan to pay for procedure codes 29540-LT and 29540-RT. You say that you disagree with the 
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 claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 29540-LT and 29540-RT is 1. The MAI value for this code is 2. You billed 
2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for 
coverage of procedure codes 29540-LT and 29540-RT have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure codes 29540-LT and 29540-RT billed for date of service July 5, 2023.