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

 
We decided that the Plan does not have to pre-approve a pneumatic appliance (E0656). 
 You asked the Plan to pre-approve a pneumatic compression device and a pneumatic appliance. You say that 
the requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules 
for coverage for PCDs have not been met. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. 
 
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, the record shows that the item denoted by code E0656 
has been requested for use with a PCD coded as E0652. The case record does not show that the enrollee has 
lymphedema extending onto the chest, trunk and/or abdomen. A PCD coded as E0652 is not eligible for 
coverage in the enrollees case. Because the base item is not covered, the related accessory (E0656) is not 
eligible for reimbursement. Therefore, we decided that the Plan does not have to pre-approve a pneumatic 
appliance (E0656).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Sprint peripheral nerve stimulator. 
 
You asked the Plan to pre-approve the Sprint peripheral nerve stimulator. You say that this is medically 
necessary. The Plan denied your request. The Plan says this is unproven and not medically necessary due to 
insufficient evidence of efficacy. 
 
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 Sprint peripheral nerve stimulator. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found this would be considered experimental therapy. 
 
   
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 Sprint peripheral nerve stimulator have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the Sprint peripheral nerve stimulator.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on March 3, 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 March 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on May 15, 2023, billed with 
procedure codes 73600-26-RT, 73590-26-RT, 73620-26-RT, and 73650-26-RT. 
 
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 codes. 
 
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 codes 73600-26-RT, 73590-26-RT, 73620-26-RT, and 73650-
26-RT is radiologic examination, ankle; 2 views, radiologic examination; tibia and fibula, 2 views, radiologic 
examination, foot; 2 views, and radiologic examination; calcaneus, minimum of 2 views. 
 
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 codes. Our reviewer found that the procedure report does not include 
sufficient documentation to confirm 2 views of ankle, tibia and fibula, foot, and calcaneus were examined and 
therefore cannot be verified. 
 
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 15, 2023, billed with procedure codes 
73600-26-RT, 73590-26-RT, 73620-26-RT, and 73650-26-RT.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for definitive drug testing (G0483) provided on July 12, 2023. 
 
You asked the Plan to pay for drug testing. You say that this testing was necessary and is supported in the 
medical record. The Plan denied your request. The Plan says that the physician order in this case is insufficient 
to show that the services provided were actually requested. The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
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 drug testing have been met. 
Specifically, the physician order in this case indicates that a Urine MCT All-in-One test was requested. There 
is no documentation to show what is included in this test or to list any specific drugs requested for testing. 
Therefore, we decided that the Plan does not have to pay for definitive drug testing (G0483) provided on July 
12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to par for the drugs purchased outside of the United States on April 27, 
2023. 
 
You asked the Plan to par for the drugs purchased outside of the United States. You say that the drugs were 
medically necessary. The Plan denied your request. The Plan says drugs are not covered when purchased 
outside of the United States. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and 
pre-approved care.   We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the drugs purchased outside of the United States have not been met. Specifically, drugs are not 
covered when purchased outside of the United States. Therefore, we decided that the Plan does not have to par 
for the drugs purchased outside of the United States on April 27, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided from March 1, 2022, to March 4, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this claim is a 
duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on July 20, 2022. Comparison of the two claims shows these are exact duplicates. There 
is no evidence presented to support that the billed items/services were provided twice on the same date. Based on this information, we decided that the Medicare rules for the services have not been met. Therefore, we 
decided that the Plan does not have to pay for the services provided from March 1, 2022, to March 4, 2022.
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 are in the hospital and require therapy services 
before returning home. The Plan denied your request. The Plan says you do not meet the criteria for admission 
to an IRF.  
 
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 you do not require treatment by multiple therapies. While the medical record 
supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. Your rehab needs can be safely provided in an alternate and low intensity setting such as in an SNF.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab panel provided on December 21, 2022. 
 
You asked the Plan to pay for the lab 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 lab panel 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 lab panel have not been met. Therefore, we decided that the Plan does not have to pay for the lab panel 
provided on December 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endodontic therapy (D3320), a pulp vitality tests 
(D0460), root canal obstruction (D3331), and an intraorifice barrier (D3911). 
 
You asked the Plan to pre-approve D3320, D0460, D3331, and D3911. You say that all of this dental work is 
necessary. The Plan denied your request. The Plan says the requested dental services are not medically 
necessary. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve endodontic therapy (D3320), a pulp vitality tests (D0460), root canal obstruction (D3331), and an intraorifice 
barrier (D3911).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve requesting 90 non-emergency trips, approved for24 one-
way trips, and denied 66 one-way trips 
 
You asked the Plan to pre-approve transportation.. The Plan denied your request. The Plan says any additional 
rides above 24 exceeds the benefits. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve requesting 90 non-emergency trips, approved for24 one-way 
trips, and denied 66 one-way trips
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sleep study (95810). 
 
You asked the Plan to pre-approve a sleep study. You say that this is medically necessary. The Plan denied 
your request. The Plan says this 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 a sleep study. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this patient has a longstanding diagnosis of obstructive sleep apnea and uses CPAP every 
night. The patient has dry eyes, which he attributes to the CPAP, despite very little air leak with the device. The 
patient is requesting the Inspire device. The body mass index (BMI) is 42.2, which is outside the eligibility 
range for the Inspire device. There is no question about the patient's diagnosis of obstructive sleep apnea, and 
the CPAP device is effectively treating the sleep disordered breathing. The patient is not intolerant of CPAP. 
 
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 sleep study have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a sleep study (95810).
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for genetic testing provided to the enrollee on September 7, 2021.

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 while
the provider did bill unique identifier of Z00D0, the Diagnostics Exchange Registry shows code Z00D0 is not
covered for the MoIDX program. The Plan notes review of the claim history shows a request for additional
information was sent to the provider on October 26, 2021. However, a response was not received.

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 codes. In this case, the reported
unique identifier code is not a valid code for this type of testing. Medicare rules for coverage of these services
have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing provided to the
enrollee on September 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for durable medical equipment (L0180) provided on August 9, 2022.

You asked the Plan to pay for this equipment. You say that the Plan denied your request. The Plan says there
were insufficient records provided to support the appeal. Maximus overturned the Plans denial. The Plan
requested a reopen and noted that the physician order is not sufficient to approve coverage. The Plan states
there were insufficient medical records submitted to determine the required coverage criteria were met.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that the provider,
supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to
determine if this equipment was provided appropriately. 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 pay for
durable medical equipment (L0180) provided on August 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair (PWC). 
 
You asked the Plan to pre-approve a PWC. You say that you have a hard time walking and has a history of 
knee problems and back surgery. You say that you fall a lot. You also say that you need a new power 
wheelchair because the last one was stolen. The Plan denied your request. The Plan says the requested PWC 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.  
 
The file shows that your condition can be improved by a walker, cane or manual wheelchair. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a power wheelchair (PWC).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve protective outer surface covering system identified with 
code L5962. 
 
You asked the Plan to pre-approve protective outer surface covering system. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the requested item is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that protective outer surface coverings are 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 protective outer surface covering 
system. Our reviewer says that the documentation does not support that the requested item is medically 
reasonable or necessary. Our physician reviewer found the enrollee is currently completing an inpatient 
rehabilitation stay for prosthetic training for his transradial amputation and transtibial amputation. The requested item exceeds the enrollee's medical needs. The documentation does not support that the enrollee has 
special needs for protection against unusually harsh environmental situations where it is necessary to protect 
the lower limb prosthesis beyond the level of protection that is afforded by L5704. Therefore, the enrollee does 
not meet criteria for the requested item. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of protective outer surface covering system have not been met. Therefore, we 
decided that the Plan does not have to pre-approve protective outer surface covering system identified with 
code L5962.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.  
 
You asked the Plan to pre-approve the PET scan. The Plan denied your request. The Plan says the criteria for 
coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the enrollee's neurology notes provided 
for review did not readily demonstrate any of the cardinal symptoms to suggest the presence of Parkinson's 
Disease. 
 
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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
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 services are medically 
necessary. The Plan denied your request. The Plan says the LTACH services are not medically necessary. 
 
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 there are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health Plan. Given there are offered alternatives, 
LTACH is 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
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 would benefit from this care. The Plan 
denied your request. The Plan says medical records do not support the need for an IRF admission and, the 
enrollee needs can be provided at another setting.  
 
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 enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical 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.