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

 
We decided that the Plan does not have to pre-approve the upgraded electronics. 
 
You asked the Plan to pre-approve the upgraded electronics. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the records do not show a medical need to control the 
power options with a joystick. 
 
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 upgraded electronics. Our reviewer says that the requested upgraded electronics are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the provided records indicate that the enrollee has adequate strength to manage 
standard power drives. Therefore, the reviewer found that the requested 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 the upgraded electronics have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the upgraded electronics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a high frequency chest wall oscillation device
(HFCWOD) for the enrollee.

You asked the Plan to provide coverage for a high frequency chest wall oscillation device (HFCWOD). You
say that the Plan denied your request. The Plan says the Medicare coverage criteria were not met. Maximus
overturned the Plans denial. The Plan requested a reopen stating they could not confirm any statement in the
medical record that the enrollee has a diagnosis of bronchiectasis.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that high frequency
chest wall oscillation devices are covered only for enrollees with cystic fibrosis, bronchiectasis, or certain
neuromuscular diseases. The medical records provided do not confirm the enrollee has a diagnosis required for
approval of this device. Therefore, we decided that the Plan does not have to provide coverage for a high
frequency chest wall oscillation device (HFCWOD) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a harness for upgrade to expandable controller (E2313), 
electronic connection between wheelchair controller and two or more power seating system motors (E2311), 
expandable controller (E2377), and attendant control (E2331). 
 
You asked the Plan to pre-approve a harness, electronic connection, expandable controller, and attendant 
control. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity 
has not been established. Therefore, coverage criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a harness, electronic connection, 
expandable controller, and attendant control. Our reviewer says that the requested items/services are not 
considered medically reasonable and necessary in this case. Our physician reviewer found he enrollee has 
adequate strength to manage standard power drives.  Attendant control is not medically necessary when there is 
operator control.  
 
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 harness, electronic connection, expandable controller, and attendant control 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a harness for upgrade to 
expandable controller (E2313), electronic connection between wheelchair controller and two or more power 
seating system motors (E2311), expandable controller (E2377), and attendant control (E2331).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller 
and two or more power seating system motors (E2311), expandable controller (E2377), harness for upgrade to 
expandable controller (E2313), and positioning belt/safety belt/pelvic strap (E0978). 
 
You asked the Plan to pre-approve an electronic connection, expandable controller, harness, and positioning 
belt/safety belt/pelvic strap. You say that the services are necessary. The Plan denied your request. The Plan 
says based on the documentation provided, coverage criteria has 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 an electronic connection, expandable 
controller, harness, and positioning belt/safety belt/pelvic strap. 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 adequate strength to manage standard power drives.  
                                         
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 electronic connection, expandable controller, harness, and positioning 
belt/safety belt/pelvic strap have not been met. Therefore, we decided that the Plan does not have to pre-
approve an electronic connection between wheelchair controller and two or more power seating system motors 
(E2311), expandable controller (E2377), harness for upgrade to expandable controller (E2313), and positioning 
belt/safety belt/pelvic strap (E0978).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve breast implant replacement surgery (19342-LT, Q4128, 
C1789-LT). 
 
You asked the Plan to pre-approve breast implant replacement surgery (19342-LT, Q4128, C1789-LT). You 
say that the requested procedure is medically necessary for the enrollee. The Plan denied your request. The 
Plan says the requested service/procedure is cosmetic and not a covered benefit. 
 
The Plan follows Medicare rules. Medicare rules say that reconstructive surgery is performed to restore and 
improve function and correct any deformities or abnormal structures of the body that have been caused by 
congenital defects, developmental abnormalities, trauma, infection, tumors or disease. 
 
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 breast implant replacement surgery 
(19342-LT, Q4128, C1789-LT). Our reviewer says that the service is not medically necessary. Our physician 
reviewer found that the record indicates that the enrollee has a history of bilateral breast augmentation and 
implants. The medical records provided are insufficient to establish that the requested service is for the 
treatment of an enumerated condition for which coverage is available under the rules or that the requested 
service is required for the prompt repair of accidental injury or to improve the functioning of a malformed body 
member. The elements of the coverage criteria are not satisfied. The requested service is not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of breast implant replacement surgery (19342-LT, Q4128, C1789-LT) have not 
been met. Therefore, we decided that the Plan does not have to pre-approve breast implant replacement surgery 
(19342-LT, Q4128, C1789-LT).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the upgraded electronics. 
 
You asked the Plan to pre-approve the upgraded electronics. You say that the enrollee is within 95% of the 
weight criteria. The Plan denied your request. The Plan says the notes do not show a medical need to control 
the power options through the joystick. 
 
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 upgraded electronics. Our reviewer says that the requested upgraded electronics (E2311, E2313, E2377) are not considered medically reasonable 
and necessary in this case. Our physician reviewer found the provided records support that the enrollee's upper 
extremity strength and functional ability as shown by independent in feeding support that the enrollee can 
control any power options through their own switches. Therefore, the reviewer found that the requested 
upgraded electronics are 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 upgraded electronics have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the upgraded electronics.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on January 03, 2023. 
 
You asked the Plan to pay for the office visit. You say that you are requesting reconsideration of the claim 
stating you did not get a referral for this member. 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 the office visit provided 
on January 03, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gastric peroral endoscopic myotomy (G-POEM) and 
inpatient admission. 
 
You asked the Plan to pre-approve G-POEM and inpatient admission. You say that the services are necessary. 
The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not 
been met. 
 
The Plan follows Medicare rules. Medicare rules say that endoscopy procedures are covered under certain 
circumstances. 
 
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 G-POEM and inpatient admission. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the GPOEM 
procedure is still considered investigational and does not meet criteria listed for coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of G-POEM and inpatient admission have not been met. Therefore, we decided 
that the Plan does not have to pre-approve gastric peroral endoscopic myotomy (G-POEM) and inpatient 
admission.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87640 billed for date of service August 8, 
2023. 
 
You asked the Plan to pay for procedure code 87640. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 87640 is bundled into payment for code 87641. 
 
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, we have confirmed that code 87640 
is a column II code to column I code 87641. The -59 modifier is not supported as a separate and distinct 
procedural service to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 87640 billed for date of 
service August 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapy procedures using massage (97124) provided from 
March 14, 2023, to May 16,2023. 
 
You asked the Plan to pay for the therapy procedures using massage (97124) . You say that the chiropractor is a 
covered service under your plan. The Plan denied your request. The Plan says the services are not covered 
services. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
 The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the therapy procedures using massage (97124) provided from March 14, 
2023, to May 16,2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for diapers provided on August 18, 2023. 
 
You asked the Plan to pay for diapers. You say that diapers have always been covered and you should have 
been told if they wouldn't be any longer. You say that this is a major expense for the enrollee. You say that the 
enrollee is bedridden and incontinent. The Plan denied your request. The Plan says diapers are not covered by 
Medicare or under the enrollee's medical benefits. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
The Plan does offer a supplemental benefit of $175 per month, which is put on a Plan Spending Account 
Card. This benefit could be used towards payment for OTC items, including diapers. However, aside from the 
option to use this flexible monthly allowance towards the cost of diapers, neither the Plan nor Medicare offers 
coverage of diapers under your durable medical equipment benefit. Therefore, we decided that the Plan does 
not have to pay for diapers provided on August 18, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a vacuum assisted suspension system (VASS).

You asked the Plan to provide coverage for a vacuum assisted suspension system (VASS). The Plan denied
your request. The Plan says a vacuum assisted suspension system (VASS) is not covered by Medicare.
Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the
correct criteria.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare does not cover investigational
equipment. The available clinical documentation in the case file does not support that a VASS (L5981) is
medically reasonable and necessary for the enrollee in this case. The use of vacuum pumps for residual limb
volume management and moisture evacuation systems among amputees is unproven and not medically
necessary due to insufficient evidence of safety and/or efficacy. Therefore, we decided that the Plan does not
have to provide coverage for a vacuum assisted suspension system (VASS).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2310) for a power 
wheelchair. 
 
You asked the Plan to pre-approve a wheelchair accessory. You say that the requested item is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested item 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 wheelchair accessory. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee requests a power wheelchair because of morbid obesity and shortness of 
breath. She is able to feed herself. Per Social Security Administration (SSA) 1862 (a)1(A), the requested 
accessory is not medically necessary as the enrollee has adequate strength to manage standard power drives. 
 
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 wheelchair accessory have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an electronic connection (E2310) for a power wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for an abutment supported porcelain/ceramic crown 
(D6058) provided on August 9, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you were told by a Plan representative that 
a crown would be covered. You say you have already paid out of pocket and would appreciate reconsideration 
for at least partial coverage. The Plan denied your request. The Plan says your annual maximum has been 
satisfied and no additional payment will be made. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your annual maximum dental benefit was met on November 8, 2023 when the Plan reprocessed your 
claim. The Plan approved $750 for the prefabricated abutment and $1,250 for the abutment supported crown 
which meets your $2,000 annual dental maximum. You are responsible for $150 which is the amount 
remaining over the $2,000 annual maximum. Therefore, we decided that the Plan does not have to pay more for 
an abutment supported porcelain/ceramic crown (D6058) provided on August 9, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller 
and two or more power seating system motors (E2311), harness for upgrade to expandable controller (E2313), 
and expandable controller (E2377). 
 
You asked the Plan to pre-approve an electronic connection, harness, and expandable controller. 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 an electronic connection, harness, and 
expandable controller. 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 adequate strength to 
manage standard power drives.  
 
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 electronic connection, harness, and expandable controller have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an electronic connection between wheelchair 
controller and two or more power seating system motors (E2311), harness for upgrade to expandable controller 
(E2313), and expandable controller (E2377).
Appeal type: Testing
Decision: Partially Favorable

We decided that the Plan has to pay for the services described by procedure code(s) 95937-26-51. We decided that the Plan does not have to pay for the services described by procedure code(s) 95865-26.

You asked the Plan to pay for testing services provided on April 18, 2023, billed with procedure codes 95865-26 and 95937-26-51. You say that the claim is billed correctly and should be paid. The Plan says that documentation does not support the billed code.

We decided that the Plan has to pay for the services described by procedure code(s) 95937-26-51.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the Plan did not make an appeal decision for the codes listed in this section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to provide a denial rationale for these services, we find that the denial of payment is not supported. Therefore, we decided that the Plan has to pay for the services described by procedure code(s) 95937-26-51.

We also decided that the Plan does not have to pay for the services described by procedure code(s) 95865-26.

The Plan follows Medicare rules. Medicare rules say that providers/suppliers must report services correctly. Procedures should be reported with the Current Procedural Terminology (CPT) code that describes the services performed.

We asked our coding reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services described by procedure code(s) 95865-26. Our reviewer says that documentation does not support the billed code. Our physician reviewer found that the medical records provided does not include documentation that a needle electromyography; larynx was performed on April 18, 2023, therefore this procedure 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 services described by procedure code(s) 95865-26 have not been met. Therefore, we decided that the Plan does not have to pay for the services described by procedure code(s) 95865-26.

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.