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

We decided that the Plan does not have to provide coverage for an expandable controller (E2377), 
harness (E2313), and electronic connection (E2311) for the enrollee.

You asked the Plan to provide coverage for an expandable controller (E2377), harness (E2313), and 
electronic connection (E2311). The Plan denied your request. The Plan says the denied accessories 
are not medically necessary. Maximus 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 an 
expandable controller (E2377), harness (E2313), and electronic connection (E2311). The Maximus 
Physician Reviewer determined that the enrollee is non-ambulatory and requires a power wheelchair 
for mobility and performing basic daily activities. She cannot perform pressure relief 
independently due to upper extremity weakness and requires a power wheelchair with power tilt and recline for adequate pressure relief and 
positioning.

She has sacral and gluteal pressure wounds. She requires power elevating leg rests for positioning 
of her lower extremities. It was determined that the complexity of the seating and positioning 
needs necessitates a more complex Group 3 power wheelchair base. The expandable controller with 
harness and electronic connection are necessary to operate the Group 3 power wheelchair base and 
the three power options via joystick. These components are required to operate 3 or more power 
options on a group 3 power wheelchair.

The Plan requested a reopen and argues the enrollee's upper limb strength and function are adequate 
for the enrollee to be able to control the power options using their own switches which are 
included in the allowance of these power options. The medical records show the enrollee is a 
44-year-old woman with a medical history that includes paraplegia, with stage 3 and 4 wounds. She 
is dependent on mechanical lift for transfers and requires maximal assistance for sitting balance. 
It is noted that the enrollee's right upper extremity strength is 3/5. The Plan is correct in this 
case. The available documentation supports that the enrollee's right upper extremity strength and 
function are adequate for her to control the power options using their own switches.
Consequently, the expandable controller, harness, and electronic connection are not medically 
necessary 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 an expandable controller (E2377), harness (E2313), and 
electronic connection (E2311) have not been met. Therefore, we decided that the Plan does not have 
to provide coverage for an expandable controller (E2377), harness (E2313), and electronic connection (E2311) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller (E2377), harness 
(E2313), electronic connection (E2311), cup holder (K0108) and phone holder (K0108) for the enrollee.

You asked the Plan to pre-approve an expandable controller, harness, electronic connection, cup 
holder and phone holder. You say that these items are medically necessary. The Plan denied your 
request. The Plan says that although there are three approved power options on this wheelchair, 
there is not a medical need to control these power options through the joystick. The Plan also says 
that a cup holder and phone holder do not service a medical need and cannot be covered.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for an 
expandable controller, harness and electronic connection. Our Medical Director states that 
available documentation supports that the enrollee's upper extremity strength and function are 
adequate for her to control the power options using their own switches. Consequently, the 
expandable controller, harness, and electronic connection are not medically necessary for the 
enrollee in this case. Our Medical Director found that the enrollee's condition does not meet 
criteria for coverage of an expandable controller, harness and electronic connection.

We looked at this physician's review, the file, and Medicare rules. The rules say that for 
equipment to be covered, it must primarily serve a medical purpose. The cup holder and phone holder 
at issue in this appeal do not serve a purpose that is primarily medical in nature. These items are 
available to the general public and would be helpful even to those who are not sick or injured. 
Based on this information, we decided that Medicare rules for coverage of an expandable controller, 
harness, electronic connection, cup holder and phone holder have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an expandable controller (E2377), harness 
(E2313), electronic connection (E2311), cup holder (K0108) and phone holder
(K0108) for the enrollee.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the Guardant360 testing billed for date of service August 8, 2023. 
 
You asked the Plan to pay for the billed testing. You say that the testing is standard of care and should be 
covered. The Plan denied your request. The Plan says that the claim for this testing did not include the required 
unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. A review of the claim does show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the billed testing have 
been met. Therefore, we decided that the Plan has to pay for the Guardant360 testing billed for date of service 
August 8, 2023.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care billed for dates of service April 21, 
2022, to May 20, 2022. You asked the Plan to pay for the billed services. You say that there were changed in the organization that 
affected your ability to meet the deadlines. The Plan denied your request. The Plan says the NOA was not 
received timely. 
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is April 21, 2022. The NOA was not received by the Plan until November 14, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health care billed for 
dates of service April 21, 2022, to May 20, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the over-the-counter (OTC) COVID-19 test (K1034) 
provided on June 30, 2023. 
 
You asked the Plan to pay for the OTC COVID-19 test. You say that you would like this claim to be processed 
towards payment. The Plan denied your request. The Plan says OTC COVID-19 tests, K1034, are not covered 
by Medicare after May 11, 2023. 
 The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items, including self-
administered COVID-19 tests and the OTC COVID-19 test is an OTC item. Therefore, we decided that the 
Plan does not have to pay for the over-the-counter (OTC) COVID-19 test (K1034) provided on June 30, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 11730 provided on July 26, 2023. 
 
You asked the Plan to pay for procedure code 11730. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 11730 is not supported in the medical record. Specifically, the claim was billed without 
a required anatomical modifier (FA, F1, F2, F3, F4, F5, F6, F7, F8, F9, TA, T1, T2, T3, T4, T5, T6, T7, T8, 
T9). Based on this information, we decided that Medicare rules for coverage of procedure code 11730 have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure code 11730 provided on July 
26, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee fell and broke several ribs. You say prior 
to the fall the enrollee was independent and able to perform day to day activities alone. The Plan denied your 
request. The Plan says the enrollee does not meet Medicare guidelines for services in an inpatient rehabilitation 
facility.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. At the current 
functional level, the enrollee needs physical and occupational therapy; however, the enrollee does not need 
intensive therapies consisting of at least three hours of therapy per day at least five days per week with a 
multidisciplinary approach in an IRF. The enrollees rehabilitation needs can be safely provided in an alternate 
and low intensity setting such as in a skilled nursing facility or in-home with services and family support.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the crown (D2750), the provisional crown (D2799), and 
the core build-ups (D2950) on teeth #s 5, 6, and 11. 
 
You asked the Plan to pre-approve the crown (D2750), the provisional crown (D2799), and the core build-ups 
(D2950) on teeth #s 5, 6, and 11. You say that the enrollee needs crowns on teeth #s 11, 5, and 6 due to 
extensive cavity on more than three surfaces in each tooth. The Plan denied your request. The Plan says the 
services are not medically necessary. The Plan says the x-rays do not show extensive damage. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the crown 
(D2750), the provisional crown (D2799), and the core build-ups (D2950) on teeth #s 5, 6, and 11 when the 
services are medically necessary and reasonable.  
 
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 crown (D2750), the provisional 
crown (D2799), and the core build-ups (D2950) on teeth #s 5, 6, and 11. Our reviewer says that the services are 
not medically necessary. Our physician reviewer found the radiographs provided were not of diagnostic 
quality.  A determination of the degree of coronal breakdown of teeth #'s 5, 6 and 11 could not be made to 
indicate the need for core build ups and crown restorations.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the crown (D2750), the provisional crown (D2799), the core build-ups (D2950) 
on teeth #s 5, 6, and 11, and the resin-based composite (D3330) have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the crown (D2750), the provisional crown (D2799), and the core build-
ups (D2950) on teeth #s 5, 6, and 11.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for evaluation and management services (99291) provided to the
enrollee on October 24, 2022.

You asked the Plan to pay this claim. You say that these services should be paid by the Plan. The Plan denied
your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial
for insufficient information in the case file. The Plan requested a reopen and noted this code was billed twice
for the same enrollee on two different claims by the same provider. The Plan codes with an MAI of "2" are
absolute date of service edits. These are "per day edits based on policy." Units of service on the same date of
service (DOS) more than the MUE value would be considered impossible because it was contrary to statute,
regulation, or sub regulatory guidance.

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, the records show the same provider billed code 99291 on two different
claims for the same enrollee, which is not allowed as this code is only allowed to be billed as one unit per date
of service for the enrollee. Medicare rules for coverage of this claim have not been met. Therefore, we decided
that the Plan does not have to pay for evaluation and management services (99291) provided to the enrollee on
October 24, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Infuse allograft and a Novabone allograft (20930). 
 
You asked the Plan to pre-approve an Infuse allograft and a Novabone allograft. You say that this is medically 
necessary. The Plan denied your request. The Plan says there is insufficient reliable evidence in the form of 
high-quality peer-reviewed medical literature to establish the safety and efficacy of the requested products. 
 
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 an Infuse allograft and a Novabone 
allograft. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found there is limited published, large-scale, long-term peer-
reviewed literature that shows this requested allograft to be an effective and/or safe treatment for the noted 
pathology. Further studies are needed to demonstrate this request has beneficial outcomes compared with 
conventional treatment. There is no compelling rationale presented, or extenuating circumstances noted to 
support the medical necessity of this request as an exception. 
 
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 Infuse allograft and a Novabone allograft have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an Infuse allograft and a Novabone allograft (20930).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Envarsus. 
 
You asked the Plan to pre-approve Envarsus. You say that the medication is medically necessary. 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 Envarsus.  Benefits for Envarsus 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 an addition, endoskeletal system, above knee, flexible 
protective outer surface covering system (L5964). 
 
You asked the Plan to pre-approve a prosthetic. You say that the requested prosthetics is medically necessary. 
The Plan denied your request. The Plan says the request for an L5964, extra protective cover, does not meet 
Medicare criteria as reasonable and 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 prosthetic. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has a right above the knee amputation who was approved for a new prosthetic 
replacement prosthesis due to his prior loose socket and poor functioning knee. The criteria for a protective 
outer surface covering system (L5964) have not been met per LCA A52496 as the documentation does not 
reveal 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 a standard 
prosthetic cover. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of prosthetic have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an addition, endoskeletal system, above knee, flexible protective outer surface covering system 
(L5964).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantation of the Avertix Guardian system (0525T, 
C1833). 
 
You asked the Plan to pre-approve implantation of the Avertix Guardian system. 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 implantation of the Avertix Guardian 
system. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found while the clinical studies led to FDA approval, the Avertix 
Guardian system remains the subject of studies assessing long-term efficacy, as well as randomized, controlled, blinded trials to quantify clinical efficacy. Until such statistically rigorous studies are completed, it is premature 
to presume clinical outcomes and benefit. At the current time, the Avertix Guardian system is not considered to 
be medically necessary in this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of implantation of the Avertix Guardian system have not been met. Therefore, we 
decided that the Plan does not have to pre-approve implantation of the Avertix Guardian system (0525T, 
C1833).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a hospital bed, semi-electric (head and foot adjustment), 
with any type of side rails, with mattress (E0260, E0181). 
 
 
 You asked the Plan to pre-approve a semi-electric hospital bed and mattress. You say that you request 
reconsideration due to medical necessity. The Plan denied your request. The Plan says the enrollee does not 
require frequent body position changes and/or have an immediate need for a change in position while in bed 
and therefore, not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 semi-electric hospital bed and 
mattress. Our reviewer says that the service is not medically necessary. Our physician reviewer found the 
enrollee has heart failure and cannot sleep flat. Per NCD 280.7, the record does not support the enrollee 
requires positioning not available with a standard bed. Nor does the enrollee have frequent change in position. 
There is no indication for bed attachments. 
 
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 semi-electric hospital bed and mattress have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a hospital bed, semi-electric (head and foot adjustment), 
with any type of side rails, with mattress (E0260, E0181).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 96372 provided on July 8, 2023. 
 
You asked the Plan to pay for code 96372. You say that this service was medically necessary. The Plan denied 
your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 96372 is not supported in the medical record. Specifically, this code has a status 
indicator of Q1 and was billed on the same date of service as code 99284 which has a status indicator of "V". 
Code 96372 is not separately payable in this case. Based on this information, we decided that Medicare rules 
for coverage of code 96372 have not been met. Therefore, we decided that the Plan does not have to pay for 
code 96372 provided on July 8, 2023.