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

We decided that the Plan does not have to provide coverage for a Group three power wheelchair to include an
expandable controller (E2377), harness (E2313), electronic connection between wheelchair controller and two
or more power seating system motors (E23110, and power seat elevation feature (E2300) for the enrollee.

You asked the Plan to provide coverage for an expandable controller (E2377), harness (E2313), electronic
connection between wheelchair controller and two or more power seating system motors (E23110, and power
seat elevation feature (E2300). The Plan denied your request. The Plan says the Medicare coverage criteria
were not met for those accessories denied. Maximus partially overturned the Plans denial. The Plan requested a
reopen and noted that Maximus did not apply the correct criteria. The Plan noted that management of power
features using a single joystick controller, rather than through their own switches, is not reasonable and
necessary for the enrollee's needs. The use of these electronic upgrades for enrollees who do not require them
can be burdensome. Using the joystick for all functions (control of the wheelchair, as well as control of power
tilt, power recline, and power elevating leg rests) can be quite tedious. An enrollee with adequate strength and
range of motion would find it easier to control the power wheelchair, power tilt, power recline and power
elevating leg rests with their own switches, rather than go through various menus and joystick sequences to
control the power wheelchair, then power tilt, then power recline then power elevating leg rests, then the power
wheelchair again. This is more taxing for someone with sufficient strength to control the individual switches.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare has specific coverage criteria
for the requested accessories. Based on the medical records provided, the enrollee has the upper extremity
strength needed to operate the approved power wheelchair without the upgraded electronics requested.
Therefore, we decided that the Plan does not have to provide coverage for a Group three power wheelchair to
include an expandable controller (E2377), harness (E2313), electronic connection between wheelchair
controller and two or more power seating system motors (E23110, and power seat elevation feature (E2300) for
the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on May 7, 2023, billed with 
procedure code 10061. 
 
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 documentation does not support the billed code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 10061 is incision and drainage of abscess (eg, carbuncle, 
suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); complicated or 
multiple. 
 
We asked our coder 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 practitioner services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found that the report does not support  the 
procedure code reported. There is a more appropriate code to report for documented service. 
 
We looked at this coder's review, the file, and Medicare rules. 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 May 7, 2023, billed with procedure code 
10061.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 6 home health skilled nursing visits. 
 You asked the Plan to pre-approve home health services. You say that the services are necessary. The Plan 
denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the 
documentation does not support that the enrollee requires additional skilled nursing services to provide 
treatment that is medically necessary. The enrollee does not require additional skilled nursing services to 
effectively provide treatment, care, and/or services in order to improve the enrollees condition, perform a 
maintenance program to maintain the enrollees condition and/or prevent deterioration. The enrollee has been 
medically stable without any recent exacerbations of chronic medical problems or hospitalizations. The 
requested home health services 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 6 home health skilled nursing visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Omalizumab injection rendered on
January 13, 2023.

You asked the Plan to waive the coinsurance for these services. You say that you have received the injections
for two years and they were covered by your previous insurance. 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 20%
coinsurance for Medicare Part B prescription drugs.

Review of the file shows that you received an Omalizumab injection on January 13, 2023. The previous
determination stated that the Plan had to waive the coinsurance because you could not be asked to pay the full
allowed amount. This determination was incorrect, as the Plan is not asking you to pay the full allowed amount,
but 20% of the full allowed amount. The contract with the Plan says that you have to pay a 20% coinsurance
for these services. This item/service falls within the Medicare Part B prescription drugs benefit category. A
20% coinsurance for the date of service at issue would equal $572.94; however, the Plan has asked you to pay
only $505.45, which is lower than the 20% coinsurance. 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 Omalizumab injection rendered on January 13, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve shoulder surgery (arthroscopy). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found there is no documented recent trial and 
failure of physical therapy. More conservative measures are needed prior to surgery. The requested shoulder 
arthroscopy is not reasonable or medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve shoulder surgery (arthroscopy).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transcatheter aortic valve replacement (TAVR). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that TAVR is covered when specific 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has asymptomatic severe 
aortic stenosis. The records do not support that the criteria for coverage are met for asymptomatic patients. 
There is no documentation of left ventricle ejection fraction (LVEF) less than 50 percent, a plan for coronary 
artery bypass grafting (CABG) or any other form of heart surgery, an abnormal exercise treadmill test, peak 
velocity greater than five m/sec and mean pressure gradient greater than 60, and annual progression of peak 
velocity of greater than 0.3 m/s/year. The services are therefore not reasonable or medically necesary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve transcatheter aortic valve replacement (TAVR).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Fluorouracil 5% cream. 
 
You asked the Plan to pre-approve Fluorouracil 5% cream. You say that you disagree with the Plan's denial. 
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 pre-approve Fluorouracil 5% cream.  Benefits for Fluorouracil 5% cream 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs this care to return to her prior 
level of independence. The Plan denied your request. The Plan says the enrollee's condition does not meet the 
criteria for an IRF admission.  
 
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 records do not specify any complex functional impairments, so the complexity of 
the enrollee's rehabilitation needs would not be expected to require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitation care. The records show that enrollee requires ongoing physical and 
occupational therapy but does not support the medical necessity of an intensive rehabilitation regimen in an 
IRF 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM) 
sensor. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the criteria are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not treat with 
insulin or have a history of problematic hypoglycemia with documented recurrent level two hypoglycemic 
events Based on this information, we decided that Medicare rules for coverage of these services have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose 
monitor (CGM) sensor.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Zilretta. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says that the services are 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 these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the enrollee has knee osteoarthritis. The 
Food and Drug Administration (FDA) has stated that the requested drug is indicated as an intraarticular 
injection for treatment of osteoarthritis-related knee pain. The record indicates that the enrollee had favorable 
efficacy from the previous injection. The current label does not indicate that there is a prohibition against 
repeat administration. The Zilretta is reasonable and medically necessary based on the submitted records. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pre-
approve Zilretta.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Koya Dayspring device non-pneumatic compression 
device (K1024) and compression garment (K1033). 
 
You asked the Plan to pre-approve a Koya Dayspring device and compression garment. 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 Koya Dayspring device and 
compression garment. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found there is no indication that the enrollee has 
trialed a basic pneumatic compression device and failed to respond with objective measurements. There is also a lack of medical literature indicating that the requested Koya Dayspring Device non-pneumatic compression 
device is clinically as or more efficacious than standard pneumatic compression devices. The medical literature 
largely includes pilot studies with a small number of participants. Therefore, the Koya Dayspring Device non-
pneumatic compression device and compression garment cannot be considered 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 a Koya Dayspring device and compression garment have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Koya Dayspring device non-pneumatic 
compression device (K1024) and compression garment (K1033).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a split night titration study (95811). 
 
You asked the Plan to pre-approve the sleep study. You say that an in-lab study is medically necessary due to 
the enrollee's weight loss and updated therapy. The Plan denied your request. The Plan says the request for a 
sleep study in a facility is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the sleep study. Our reviewer says that 
the requested sleep study is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the provided records indicate that the enrollee has used continuous positive airway pressure 
(CPAP) for the last 15 years, and the current 10-year-old device is failing. The reviewer found that there is a 
complaint of abdominal bloating, but the enrollee is benefiting from the device and feels that they cannot sleep without it. The reviewer found that the last sleep study was in 2013. The enrollee reports losing 20 pounds in 
weight, but this is a weight change of less than 10%. The current Epworth sleepiness score is 5. The reviewer 
found that a repeat sleep study and Pap titration would only be necessary if the new device is not effectively 
treating your sleep disordered breathing. Therefore, the reviewer found that the requested sleep study 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 sleep study have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a split night titration study (95811).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from April 18, 
2023, to May 17, 2023. 
 You asked the Plan to pay for SNF care. You say that  the services should be covered under the Medicare Act. 
The Plan denied your request. The Plan says the enrollee did not meet the criteria for a daily skilled nurse or 
therapist. 
 
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 pay for 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 the enrollee did not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs 
that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did 
not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (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 pay for skilled nursing facility (SNF) care provided from April 18, 2023, to May 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for dental code D6192 under the medical benefit.

You asked the Plan to provide coverage for code D6192 under the enrollee's medical benefit. The Plan denied
your request. The Plan says dental code D6192 is not covered the dental benefit. The Plan noted dental codes
are not covered under the general medical necessity benefit. Maximus overturned the Plans denial. The Plan
requested a reopen and noted that Maximus did not apply the correct criteria. The Plan noted that D6192 is not
listed in the Schedule of Coverage Benefits and therefore is not eligible for coverage.

The Plan is correct in this case. Medicare does not cover dental services. The Plan offers a dental benefit that
exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Whether or not the
dental service was appropriate for the enrollee's condition is not of issue. Dental services are a supplemental
benefit. The dental services requested, D6192, are not listed as a covered benefit under the enrollee's contract.
These types of services are not covered under the medical benefit.

Therefore, we decided that the Plan does not have to provide coverage for code D6192 under the medical
benefit.