Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device (22869). 
 
You asked the Plan to pre-approve the Vertiflex device. You say that this is medically necessary. The Plan 
denied your request. The Plan says unproven and not medically necessary procedures are not covered due to 
insufficient evidence of coverage. 
 
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 Vertiflex device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Vertiflex device is experimental. 
 
   
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 Vertiflex device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex device (22869).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for a rowing membership purchased on April 13, 
2023. 
 
You asked the Plan to reimburse you for a rowing membership. You say that this should be covered. The Plan 
denied your request. The Plan says rowing is not reimbursable under the wellness allowance as it's not a 
qualified fitness center. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The plan reimburses you 
towards your cost for membership in a qualified health club or fitness facility during the calendar year. 
 
   
The Plans rules for coverage of gym benefits have not been met because Rowing is not reimbursable under 
wellness allowance as it's not a qualified fitness center.. Therefore, we decided that the Plan does not have to 
reimburse you for a rowing membership purchased on April 13, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage for routine transportation (A0170). 
 
You asked the Plan to pre-approve additional mileage for routine transportation. You say that you need 
transportation to your medical appointment. The Plan denied your request. The Plan says your benefit only 
allows 24 one-way trips with each one-way trip not exceeding 50 miles of driving distance. 
 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 routine transportation when the driving distance for a one-way trip is within 50 miles.  
 
We looked at your request, the records in the case file, and the rules. Specifically, the provider is located 56.5 
miles away from your residence. The Plan only covers distances up to 50 miles. Based on this information, we 
decided that the Plans rules for coverage of routine transportation have not been met. Therefore, we decided 
that the Plan does not have to pre-approve additional mileage for routine transportation (A0170).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance treatment without transport provided on May 8, 
2023. 
 
You asked the Plan to pay for the ambulance treatment without transport. You say that the services should be 
covered. The Plan denied your request. The Plan says the Medicare ambulance benefit is a transportation 
benefit and without a transport there is no payable service. 
 
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 May 8, 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 ambulance treatment without transport provided 
on May 8, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide reimbursement for the fitness rebounder and exercise ball
purchased on March 2, 2023.

You asked the Plan to provide reimbursement for the fitness rebounder and exercise ball. You say that you are
requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that
these items are not covered under the wellness allowance benefit. Maximus overturned the Plan's denial based
on a lack of information. The Plan has requested a reopening and stated that fitness equipment is not
reimbursable. The Plan is correct in this case. The EOC states that the Wellness Allowance reimburses you up
to $150 per calendar year towards your cost for membership in a qualified health club or fitness facility during
the calendar year, covered instructional fitness classes, participation in wellness programs, memory fitness
activities, acupuncture, and/or covered nutritional counseling sessions with a licensed nutritional counselor or
registered dietician. The contract does not indicate coverage for health equipment reimbursement. Therefore,
we decided that the Plan does not have to provide reimbursement for the fitness rebounder and exercise ball
purchased on March 2, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc or Synvisc-one (J7325). 
 You asked the Plan to pre-approve Synvisc or Synvisc-one. You say that this is medically necessary for the 
enrollee's treatment for osteoarthritis of the knee. The Plan denied your request. The Plan says the member has 
not tried and failed one of the preferred step therapy (multi-injection) device(s): Orthovisc OR Supartz FX. The 
Plan also says there is no indication their preferred agent(s) would likely be less effective, and/or cause adverse 
effects for the member.  
 
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 Synvisc or Synvisc-one. Our reviewer 
says that the enrollee does not meet the criteria for Synvisc or Synvisc-one. Our physician reviewer found 
based on the medical records provided there is no indication that the enrollee has tried and failed the required 
drug(s). Our physician reviewer also found that based on the medical records provided and the Medicare-
approved major drug compendia there is no indication that the Plan's required drugs would likely be less 
effective and/or likely have adverse effects for the 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 Synvisc or Synvisc-one have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Synvisc or Synvisc-one (J7325).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unlisted neurological or neuromuscular diagnostic 
procedure (95999) provided August 14, 2023. 
 
You asked the Plan to pay for a diagnostic procedure. You say that the claim should be paid. The Plan denied 
your request. The Plan says the service is not supported by the records. 
 
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 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 diagnostic procedure. Our reviewer says that the service does 
not meet criteria for approval of payment on this claim. Our reviewer found 95999 is not supported. According 
to the case file, this unlisted code was used to report train of four testing during intraoperative neuromonitoring. 
According to CPT and National Correct Coding Initiative (NCCI) rules, train of four testing is not a separately 
reportable service and is included in intraoperative neuromonitoring, it should not be reported with 95999 or 
any other code. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a diagnostic procedure have not been met. Therefore, we decided that the Plan 
does not have to pay for the unlisted neurological or neuromuscular diagnostic procedure (95999) provided 
August 14, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ondansetron. 
 
You asked the Plan to pre-approve Ondansetron. You say that the enrollee needs for relief of nausea when at 
home. 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. While Ondansetron may be covered by Medicare Part B, this request is not covered 
because it will not be used as a full therapeutic replacement for intravenous anti-emetic drugs during a 
chemotherapy regimen. Therefore, we decided that the Plan does not have to pre-approve Ondansetron.  
 
Benefits for Ondansetron 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 pay for the cervical traction equipment (E0849) provided on May 10, 
2023. 
 
You asked the Plan to pay for the cervical traction equipment. You say that the items were medically 
necessary. The Plan denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. The clinical documentation submitted does not support the items were needed, discussed or 
ordered by the treating physician. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for the cervical 
traction equipment (E0849) provided on May 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transforminal epidural steroid injection. 
 
You asked the Plan to pre-approve the injection. The Plan denied your request. The Plan says a transforminal 
epidural steroid injection 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 injection. Our reviewer says that a 
transforminal epidural steroid injection is not medically necessary. Our physician reviewer found that the 
enrollee had a bilateral L1-L2 transforminal epidural steroid injection on September 6, 2023. However, there is 
no documentation of 50% pain relief for three months. Therefore, the request is not medically reasonable and 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a transforminal epidural steroid injection.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on July 19, 2023, billed with 
codes 81433. 
 
You asked the Plan to pay for the genetic testing billed. You say that this service was medically necessary. The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
July 19, 2023, billed with codes 81433.
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 requesting reconsideration of the denied IRF 
admission. The Plan denied your request. The Plan says IRF care is not reasonable and necessary.  
 
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. 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 records support a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. There is not a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 36620 and 76937 billed on date of service 
June 21, 2023. 
 
You asked the Plan to pay for 36620 and 76937. You say that 36620 and 76937 should be paid as billed 
because they are supported in the documentation. The Plan denied your request. The Plan says 36620 and 
76937 are denied because they are not supported in the documentation. 
 
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 36620 is arterial catheterization or cannulation for 
sampling, monitoring or transfusion (separate procedure); percutaneous. The CPT Code Manual definition of 
code 76937 is ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, 
documentation of selected vessel patency, concurrent real-time ultrasound visualization of vascular needle 
entry, with permanent recording and reporting (list separately in addition to code for primary procedure). 
 
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 36620 and 76937. Our reviewer says that 36620 and 76937 
are not supported in the provided documentation. Our reviewer found regarding code 36620, the medical record 
does not include a procedure report for arterial catheterization or cannulation. This procedure was not found in 
the documentation. Regarding code 76937, the medical record does not include documentation of ultrasound 
guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of 
selected vessel patency, concurrent real-time ultrasound visualization of vascular needle entry, with permanent 
recording and reporting. This procedure was also not found in the documentation. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 36620 and 76937 have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure codes 36620 and 76937 billed on date of service June 21, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound filler (A6010) and foam dressing (A6212) provided 
on June 15, 2023. 
 
You asked the Plan to pay for wound filler (A6010) and foam dressing (A6212). You say that the items should 
be covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for wound filler (A6010) 
and foam dressing (A6212) provided on June 15, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Monovisc. 
 You asked the Plan to pre-approve the drug. You say that you had surgery and need the shot. You say that your 
leg is not getting better. The Plan denied your request. The Plan says that 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 the drug. Our reviewer says that 
Monovisc is not medically necessary. Our physician reviewer found that the documentations does not outline 
contraindications or reasons the Plan's required drugs were not considered or that the Plan's required drugs 
would likely be less effective or likely have adverse effects for you. Therefore, Monovisc is not approved as 
the step therapy criteria have not been met. 
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Monovisc.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dual mode battery charger (E2367). 
 
You asked the Plan to pre-approve a dual mode battery charger. You say that the item is medically necessary. 
The Plan denied your request. The Plan says the item is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that a single mode battery charger (E2366) is appropriate 
for charging a sealed lead acid battery. If a dual mode battery charger (E2367) is provided as a replacement, it 
will be denied as not reasonable and necessary.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a dual mode battery charger have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a dual mode battery charger (E2367).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cervical traction equipment (E0849) provided on July 2, 
2023. 
 
You asked the Plan to pay for the cervical traction equipment. You say that the item was medically necessary. 
The Plan denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. There is no indication this item was needed, discussed or ordered by the treating physician in the 
medical records submitted. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for the cervical 
traction equipment (E0849) provided on July 2, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hydromorphone. 
 
You asked the Plan to pre-approve Hydromorphone. You say that it is needed for pain control. 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 Hydromorphone.   
Benefits for Hydromorphone may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.