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

 
We decided that the Plan does not have to pay for the knee orthosis and related accessory billed for date of 
service May 8, 2023. 
 
You asked the Plan to pay for the billed services. 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 a valid physician order or relevant medical records which support medical 
necessity for the supplies provided in this case. The medical records do not show that the enrollee was seen or 
treated for any knee condition. The records do not show that the enrollees treatment plan included an orthosis.  
Based on this information, we decided that the Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pay for the knee orthosis and related accessory billed for date of service 
May 8, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a K3 microprocessor knee (L5828, L5845,
L5848, and L5856).

You asked the Plan to provide coverage for this prosthetic equipment. You say that this equipment was
medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria were not met.
Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the
correct criteria. The Plan noted that based on the medical records provided, the enrollee uses a walker outside
and a cane inside.

The medical records do not indicate why a K2 or K3 mechanical knee would not serve the enrollees needs. In
addition, it does not show the prior authorization request was appropriately coded as codes L5828, L5845,
L5848 and L5856 are considered to be one unit and cannot be requested or billed separately as all of these
codes are needed to build this single knee.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that for Medicare to
consider coverage and payment for any item or service, the information submitted by the supplier or provider
must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare
coverage criteria have been met. We looked at the file and Medicare rules. Based on this information, we
decided that there is insufficient information in the record to determine if Medicare rules for coverage of this
prosthetic equipment have been met as the medical record documentation does not confirm the enrollee was a
K3 ambulator and/or that the enrollees need could not be met with a mechanical knee. Therefore, we decided
that the Plan does not have to provide coverage for a K3 microprocessor knee (L5828, L5845, L5848, and
L5856).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve L1 kyphoplasty (22514). 
 
You asked the Plan to pre-approve L1 kyphoplasty. You say that this is medically necessary. The Plan denied 
your request. The Plan says medical necessity coverage criteria are not met. 
 
The Plan follows Medicare rules. Medicare rules say that kyphoplasty can be covered when specific criteria are 
met. 
 
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 L1 kyphoplasty. Our reviewer says that 
you do not meet criteria for coverage. Our physician reviewer found there is no imaging study that shows a 
recent acute fracture that is less than 6-12 weeks old. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of L1 kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve L1 kyphoplasty (22514).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee will need inpatient 
admission after surgery. The Plan denied your request. The Plan says the surgery is not on the inpatient only 
list. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the surgery code is not on the Medicare Inpatient Only List. The documentation pre-
operatively does not meet the threshold for an intensity of services or underlying member hemodynamic 
instability that could only be managed in an acute inpatient setting. The record does not show that at the time of 
inpatient admission it was reasonable for the admitting physician to expect that the patient's necessary hospital 
care would span two midnights with supporting documentation of the patient's history and comorbidities, signs 
and symptoms, current medical needs, and risk of an adverse event. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Kenevo microprocessor knee and flex-walk foot for
the enrollee.

You asked the Plan to pre-approve a Kenevo microprocessor knee and flex-walk foot. You say that these items
are medically necessary. The Plan denied your request. The Plan says that based on the documentation
provided, coverage criteria has not been met.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for a Kenevo
microprocessor knee and flex-walk foot. Our Medical Director states that the enrollee underwent a left
transfemoral amputation in July of 2020 in the setting of peripheral arterial disease. The enrollee received a K2
prosthesis. The enrollee decided not to use this prosthesis and has been ambulating using only his right leg and
a rolling walker. On April 4, 2023, it is documented that the enrollee's socket was locked at 35 degrees left hip
flexion contracture. The provider documents that the enrollee is a K3 ambulator and is expected to remain at
that level. A level 3 ambulator is defined as having the ability or potential for ambulation with variable
cadence. Typical of the community ambulator who has the ability to traverse most environmental barriers and
may have vocational, therapeutic, or exercise activity that demands prosthetic utilization beyond simple
locomotion. The available clinical documentation is insufficient to demonstrate that the enrollee in this case
meets that coverage criteria. Our Medical Director found that the enrollee's condition does not meet criteria for
coverage of a Kenevo microprocessor knee and flex-walk foot.

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 Kenevo microprocessor knee and flex-walk foot have not been met.
Therefore, we decided that the Plan does not have to pre-approve a Kenevo microprocessor knee and flex-walk
foot for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 12 physical therapy visits (97110). 
 
You asked the Plan to pre-approve the therapy services. 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. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 12 physical therapy visits. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found the treatment has not impacted the enrollee significantly. 
The indication for continued therapy based on response to prior therapy is not provided. The rationale for 
continued therapy based on response has not been provided and the evidence is therapy has limited efficacy for 
the enrollee's pain. She is able to perform repetitive home exercises consistent with her therapy.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 12 physical therapy visits have not been met. Therefore, we decided that the 
Plan does not have to pre-approve 12 physical therapy visits (97110).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 3 home health skilled nursing visits (G0299).  
You asked the Plan to pre-approve home health services. You say that the services are necessary. The Plan 
denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found clinical 
documentation does not specify any change in medications, plan of care, clinical status or wound care needs. 
The records do not show that 3 additional home health skilled nursing visits are required to effectively provide 
treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a 
maintenance program to maintain the enrollee's condition and/or prevent deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 3 home health skilled nursing visits (G0299).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87150 billed for date of service February 14, 
2023. 
 
You asked the Plan to pay for the billed service. The Plan denied your request. The Plan says the records do not 
support the coding. 
 
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 87150 is culture, typing; identification by nucleic acid 
(DNA or RNA) probe, amplified probe technique, per culture or isolate, each organism probed. The file shows that a urinary tract infection panel was provided. We looked at the file and the rules. We find 
that 12 units of CPT code 87150 is not supported in the medical record. Based on this information, we decided 
that Medicare rules for coverage of the billed service have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 87150 billed for date of service February 14, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 87186 provided on January 26, 2023. 
 
You asked the Plan to pay for procedure code 87186. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered. 
 
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 87186 is Susceptibility studies, antimicrobial agent; microdilution or agar dilution (minimum inhibitory 
concentration [MIC] or breakpoint), each multi-antimicrobial, per plate. 
 
We find that CPT code 87186 is supported in the medical record. Specifically, the laboratory report shows 
susceptibility studies were performed. Based on this information, we decided that Medicare rules for coverage 
of procedure code 87186 have been met. Therefore, we decided that the Plan has to pay for procedure code 
87186 provided on January 26, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power mobility device (PMD). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The 
rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. 
 
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 these services. Our reviewer says that 
the criteria for coverage are not met. Our physician reviewer found the documentation dated August 16, 2023 
states that you have difficulty walking due to pain and arthritis of the hip and neck. You have normal range of 
motion and strength. A home mobility evaluation performed on November 27, 2023 indicated that you use a 
walker for assistance with mobility. The PMD is being requested for community mobility. The home mobility 
assessment indicates that you can ambulate within in your home and building with the assistance of walker and 
are modified independent with performing her daily activities. You do not require a PMD for mobility and 
performing daily activities. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Furthermore, the PMD is being requested for 
use outside of the home and Medicare does not cover this item for this use. Therefore, we decided that the Plan 
does not have to pre-approve a power mobility device (PMD).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom foot orthotics and heel lift. 
 
You asked the Plan to pre-approve foot orthotics. You say that you have had four surgeries and are unable to 
bend your knee. 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 custom foot orthotics and heel lift.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee's needs cannot be met in a 
lower level of care due to complex acuity of the enrollee's condition. The Plan denied your request. The Plan 
says LTACH services are not required, and when the enrollee is ready to leave the hospital, they can receive 
care in another setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that at the time of the request for LTACH services, the enrollee is medically stable. 
They do not require services at the LTACH that are not available at the acute care hospital where they are 
currently receiving care. There are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the Plan. The requested LTACH services are not medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and services are able to 
be furnished safely and effectively only on an inpatient basis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81000 for date of service June 9, 2023. 
 
You asked the Plan to pay for procedure code 81000. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not supported. 
 
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 81000 is urinalysis, by dip stick or tablet reagent for 
bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any 
number of these constituents; non-automated, with microscopy. 
 
We find that CPT code 81000 is not supported in the medical record. Specifically, the documentation submitted 
did not indicate that this was non-automated and does not include microscopy results. There is a more 
appropriate code to be billed for the services rendered. Based on this information, we decided that Medicare rules for coverage of procedure code 81000 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 81000 for date of service June 9, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultraviolet light therapy system provided on March 29, 
2023. 
 
You asked the Plan to pay for the ultraviolet light therapy system. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the documentation does not support that the enrollee 
met criteria for the items rendered. 
 
The Plan must follow Medicare rules. Medicare rules say that ultraviolet cabinet is covered for selected patients 
with generalized intractable psoriasis. 
 
We looked at the file and Medicare rules. Review of the file does not support that the enrollee has a diagnosis 
of psoriasis. This means the enrollee did not meet criteria for the items rendered. Based on this information, we 
decided that Medicare rules for coverage of the ultraviolet light therapy system have not been met. Therefore, we decided that the Plan does not have to pay for the ultraviolet light therapy system provided on March 29, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 power wheelchair (PWC) with single power 
option and upgraded electronics. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a PWC is covered when specific criteria are met. 
 
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 these services. Our reviewer says that 
the criteria for coverage are not met. Our physician reviewer found the records do not support that the enrollee 
uses intermittent catheterization for bladder management or needs a power seating system to manage increased 
tone or spasticity. There is no documented in-person skin evaluation. The physical therapy notes state he is still 
in therapy at the time of evaluation on November 2, 2023. It is unclear if he has made any physical progress in 
therapy and is able to weight shift or has had any change in function. The documentation does not reveal that 
he has a mobility deficit that impairs mobility-related activities of daily living (MRADLs) and is unable to be 
helped by a walker, cane, or manual wheelchair due to weakness. Without an accurate in-person updated evaluation of the enrollee's condition and actual medical visit progress notes, the PWC with accessories cannot 
be deemed to be medically necessary.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Group 2 power wheelchair (PWC) with single power option and upgraded electronics.