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

We decided that the Plan does not have to provide coverage for a Positional rotation unit or adaptor (K1022), Suspension sleeve (L5695), and a Covering system (L5964).
You asked the Plan to provide coverage for a Positional rotation unit or adaptor (K1022), Suspension sleeve (L5695), and a Covering system (L5964). You say that at the time of the appeal this equipment was medically necessary. The Plan denied your request. The Plan says the Medicare coverage criteria were not met.
Maximus partially overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for a Positional rotation unit or adaptor (K1022), Suspension sleeve (L5695), and a Covering system (L5964). The medical records show you underwent a left above-knee amputation following traumatic injury. Based on the medical records provided, the Plan is correct in this case. The available physician documentation does not support that the requested additional features for a prosthesis (K1022 and L5695) were medically reasonable and necessary at the time of the request. 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 Positional rotation unit or adaptor (K1022), Suspension sleeve (L5695), and a Covering system (L5964) have not been met. Therefore, we decided that the Plan does not have to provide coverage for a Positional rotation unit or adaptor (K1022), Suspension sleeve (L5695), and a Covering system (L5964).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia for abdominal procedure including use of 
endoscope provided on January 25, 2022. 
 
You asked the Plan to pay for the anesthesia for abdominal procedure including use of endoscope. The Plan 
denied your request. The Plan says the claim was filed untimely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the anesthesia for abdominal procedure including use of endoscope was not 
filed until February 5, 2023. This means that more than one calendar year from the date of service had passed 
before a claim was filed. Therefore, we decided that the Plan does not have to pay for anesthesia for abdominal 
procedure including use of endoscope provided on January 25, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on January 29, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you were 
unaware of these charges and therefore feel you should not be responsible to pay for these services. The Plan 
denied your request. The Plan says these services are not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on January 29, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on January 29, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for code J3490 billed to the enrollee for date of service July 5,
2022.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial stating
the code was valid. The Plan requested a reopen and demonstrated that the unlisted code J3490 for NDC
00409115902 was properly denied, because Bupivacaine is a local anesthetic agent that cannot be separately
reimbursed from the injection procedure 27096 that was billed on the same claim. Per Medicare Claims
Processing Manual Chapter 12, Section 30.5.C - Therapeutic, prophylactic, and diagnostic injections and
infusions (excluding chemotherapy): A therapeutic, prophylactic, or diagnostic IV infusion or injection, other
than hydration, is for the administration of substances/drugs. The fluid used to administer the drug(s) is
incidental hydration and is not separately payable.
If performed to facilitate the infusion or injection or hydration, the following services and items are included and are not separately billable:
1. Use of local anesthesia;
2. IV start;
3. Access to indwelling IV, subcutaneous catheter or port;
4. Flush at conclusion of infusion; and
5. Standard tubing, syringes and supplies.
Payment for the above is included in the payment for the chemotherapy administration or non-chemotherapy injection and infusion service. Per the above Medicare guidelines, the Plan has correctly denied J3490 for payment as payment for the local anesthetic is included in the payment for the chemotherapy administration or non-chemotherapy injection and infusion service
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this case, payment for code J3490 in this case was included in the payment for the administration and infusion services. Medicare rules for coverage of this service have not been met. Therefore, the Plan is not required to pay for these services as billed.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you were independent prior to being admitted to the 
hospital and IRF services are medically necessary. The Plan denied your request. The Plan says the enrollee's 
needs falls under custodial care which is not a covered benefit. 
 
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 that the complexity of the enrollee's nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee was admitted for congestive heart failure and urinary tract infection. Medical problems are stable. 
There are no complex nursing or rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. 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. 
 
There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
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 IRF admission and services.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xgeva. 
 You asked the Plan to pre-approve Xgeva. You say that the enrollee would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the step therapy requirements have not been 
met. 
 
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 Xgeva. Our reviewer says that Xgeva is 
not medically necessary. Our physician reviewer found that the enrollee has not tried and failed the required 
drug intravenous pamidronate or zoledronic acid. The documentation does not support that intravenous 
pamidronate or zoledronic acid would likely be less effective or would likely have adverse effects for the 
enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Xgeva have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Xgeva.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee would like reconsideration because the 
services are medically necessary. The Plan denied your request. The Plan says an IRF admission is not 
medically necessary, and the enrollee needs can be met in 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 that 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the electronic connection (E2311), expandable 
controller (E2377), and harness (E2313). 
 
You asked the Plan to pre-approve the electronic connection, expandable controller, and harness. You say that 
the items are medically necessary. The Plan denied your request. The Plan says the items 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 the electronic connection, expandable 
controller, and harness. Our reviewer says that the requested items are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the patient's upper extremity strength and functional 
ability should be sufficient to control any power options through their own switches.  
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 electronic connection, expandable controller, and harness have not been 
met. Therefore, we decided that the Plan does not have to pre-approve the electronic connection (E2311), 
expandable controller (E2377), and harness (E2313).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous positive airway pressure device (CPAP) 
(E0601) and accessories. 
 
You asked the Plan to pre-approve a CPAP device and accessories. You say that the items are medically 
necessary. The Plan denied your request. The Plan says the items are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that if a claim for an E0601 is submitted and all of the 
coverage criteria listed in the Medicare Rules section have not been met, it will be denied as not 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 a CPAP device and accessories. Our 
reviewer says that the enrollee does not need these items. Our physician reviewer found there is no 
documentation of a diagnosis of obstructive sleep apnea. This patient was seen on January 25, 2023, with 
diagnoses of atrial fibrillation, coronary artery disease and a previous myocardial infarction. There is no 
mention of sleep related symptoms or obstructive sleep apnea. The records do not include results of 
polysomnography. The denial is upheld. 
 
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 CPAP device and accessories have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a continuous positive airway pressure device (CPAP) (E0601) and 
accessories.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a raised toilet seat. 
 
You asked the Plan to pre-approve a raised toilet seat. The Plan denied your request. The Plan says a raised 
toilet seat is not a covered benefit under the enrollee's Medicare plan. 
 
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered 
because they are not primarily medical in nature.  
 
While a raised toilet seat 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 raised toilet seat.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Apligraf, per sq cm x4400 units (Q4101). 
 
You asked the Plan to pre-approve the Apligraf. You say that the services are medically necessary  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 the Apligraf. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the review has determined that skin substitutes are routinely applied 10 times over a three-
month period. Allowing for 50 percent wastage, the enrollee would require 15 units of skin substitute to treat her wound. The requested amount is not medically necessary. The review has determined that the 
items/services at issue in this case are 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 Apligraf have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Apligraf, per sq cm x4400 units (Q4101).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the upgraded electronics (E2311, E2377, E2313).  
 
You asked the Plan to pre-approve the upgraded electronics. You say that the requested items are medically 
necessary. The Plan denied your request. The Plan says the upgraded electronics are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that upgraded electronics are covered when it is medically 
necessary to control the power options through the joystick. 
 
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 upgraded electronics. Our reviewer 
says that these items are not medically necessary. Our physician reviewer found that the enrollee does not 
require non-proportional input devices. The enrollee also does not require a separate display, other electronic 
devices, or an attendant control. The documentation does not support that it is medically necessary to control 
the requested power options through the joystick (drive interface). The enrollees upper extremity strength and 
functional ability as evidenced by being independent for feeding and grooming/hygiene should be sufficient to 
control any power options through their own switches.  
 
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 upgraded electronics have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the upgraded electronics (E2311, E2377, E2313).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the upgraded electronics (E2377, E2311, E2313). 

You asked the Plan to pre-approve the upgraded electronics. You say that the requested power wheelchair is medically necessary for the enrollee. The Plan denied your request. The Plan says the requested features exceed the enrollee's need.

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 upgraded electronics. Our reviewer says that the requested upgrade electronics are not considered medically reasonable and necessary in this case.  Our physician reviewer found the provided documentation indicates the enrollee has use of the upper extremity and can operate and control the power options using the switches that are included in the basic wheelchair. Therefore, the reviewer found that the upgraded electronics are 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 upgraded electronics have not been met. Therefore, we decided that the Plan does not have to pre-approve the upgraded electronics (E2377, E2311, E2313).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 76942 and 99100 billed for date of service 
October 20, 2022. 
 
You asked the Plan to pay for the billed services. You say that medical records were provided. The Plan denied 
your request. The Plan says the billed codes cannot be verified. 
 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 76942 is ultrasonic guidance for needle placement (e.g., 
biopsy, aspiration, injection, localization device), imaging supervision and interpretation. We find that CPT 
code 76942 is not supported in the medical record. Specifically, the records do not include ultrasonic guidance 
with imaging supervision and interpretation.  
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of the billed services have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure codes 76942 and 99100 billed for date of service October 20, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve an office visit . You say that the patient is requesting to use a company 
Better Balance. The Plan denied your request. The Plan says this is available in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the heel wedge (L3340).  
 
You asked the Plan to pre-approve foot orthotics. You say that the item is medically necessary. The Plan 
denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve the heel wedge (L3340).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on December 2, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that this claim 
should be paid as there was a valid medical reason for calling and influence from the emergency medical 
technicians to decline transport. The Plan denied your request. The Plan says these services are not a covered 
benefit.  
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
 
 The ambulance company did not provide transport services on December 2, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on December 2, 2022.