Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction (92015) performed on January 3, 2023. 
 You asked the Plan to pay for an eye refraction. You say that this should be covered. The Plan denied your 
request. The Plan says the service at issue is not covered. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. 
 
We looked at the file and the Plan's rules.  Based on this information, we decided that the Plan's rules for 
coverage of an eye refraction have not been met. Specifically, eye refraction is only covered by the Plan when 
it is performed as part of a routine screening by a participating provider. This service was performed for 
medical vision purposes, and therefore is not a covered benefit. Therefore, we decided that the Plan does not 
have to pay for an eye refraction (92015) performed on January 3, 2023.
Appeal type: Surgery
Decision: Unfavorable

We have decided to dismiss the Plan's request to reopen the case because it does not qualify for reopening.
We can reopen a case when a plan submits important new information. Information is considered new only
if it was not available to the Medicare Plan or under the Plan's control at the time the case was submitted.
We have reviewed the information that the Plan submitted. This information was in the original case file
and previously reviewed by our physician. That is why the case does not qualify for reopening. Our
decision remains that the Plan has to pay for to pay for codes 63056, 63057, 20939, and 20937 provided
on June 10, 2022
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 90833 billed for date of service August 23, 
2022. 
 
You asked the Plan to pay for the billed services. You say that medical records were provided. The Plan denied 
your request. The Plan says the rules for payment have not been met. 
 
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 90833 is psychotherapy, 30 minutes with patient when 
performed with an evaluation and management service (List separately in addition to the code for primary 
procedure). 
 We find that CPT code 90833 is not supported. Specifically, this add-on code was not billed with a primary 
procedure code. Based on this information, we decided that Medicare rules for coverage of the billed services 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 90833 billed 
for date of service August 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS HF system (33289, 93451). 
 
You asked the Plan to pre-approve a CardioMEMS HF system. You say that the enrollee urgently needs this 
device and procedure due to her worsening heart failure. The Plan denied your request. The Plan says the 
CardioMEMS device has been determined to be of uncertain value in the most recent 2022 ACC/AHA 
guidelines and carries a risk of significant complications including death and severe pulmonary artery injury. 
 
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 CardioMEMS HF system. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the CardioMEMS device was approved by the FDA in 2014 and consists of 
a sensor device placed in the pulmonary artery to allow measurement of pulmonary artery pressure in the 
management of enrollees with CHF. The clinical study on which FDA approval was based showed improved 
clinical outcomes and decreased hospitalizations in enrollees in whom the CardioMEMS system was 
implanted, reflecting an enrollee population with preserved ejection fraction and was somewhat limited in 
scope. Subsequent follow-up studies remain encouraging and suggest an improvement in heart failure 
symptoms with the use of the device. In addition, published expert opinion in the cardiology literature is 
supportive of the clinical usefulness of CardioMEMS. Nonetheless, there remains a dearth of randomized, 
blinded clinical studies examining long-term clinical outcomes establishing the value of CardioMEMS in 
enrollee management. As a result, at this time the CardioMEMS system would not be considered medically 
appropriate and necessary in this enrollees clinical management. 
 
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 CardioMEMS HF system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a CardioMEMS HF system (33289, 93451).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller upgrade with harness, 
electronic connection, gel armpads, flip foot platform, and super soft foam. 
 
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 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has spastic quadriplegia 
but is very active. He is able to transfer independently from the wheelchair and is able to pull himself to a 
standing position. The records do not support that the requested expandable controller with harness upgrade 
and electronic connection are 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.  
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The requested gel armpads, flip foot platform, and super soft foam do not serve a purpose that is primarily 
medical in nature. 
 
Therefore, we decided that the Plan does not have to pre-approve an expandable controller upgrade with 
harness, electronic connection, gel armpads, flip foot platform, and super soft foam.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultra-light material (L5940), socket insert with locking 
mechanism (L5673), multi-axial ankle (L5979), molded socket (L5301), acrylic socket (L5629), alignable 
system (L5910), total contact (L5637), test socket (L5620) multiple ply prosthetic sock (L8420), and single ply 
prosthetic sock (L8470) provided on October 14, 2021. 
 
You asked the Plan to pay for the ultra-light material, socket insert with locking mechanism, multi-axial ankle, 
molded socket, acrylic socket, alignable system, total contact, test socket, and prosthetic socks. You say that 
these services are related to injuries sustained from an automobile accident, and our auto carrier has been the 
primary insurer for all injuries related to the accident. You also say that the primary insurance denied coverage, 
other insurances were billed, and the Plan finally got its bill. The Plan denied your request. The Plan says this 
claim was submitted after the timely filing limitations. 
 The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the ultra-light material, socket insert with locking mechanism, multi-axial 
ankle, molded socket, acrylic socket, alignable system, total contact, test socket, and prosthetic socks was not 
filed until February 3, 2023. This means that more than one calendar year from the date of service had passed 
before a claim was filed. Therefore, we decided that the Plan does not have to pay for the ultra-light material 
(L5940), socket insert with locking mechanism (L5673), multi-axial ankle (L5979), molded socket (L5301), 
acrylic socket (L5629), alignable system (L5910), total contact (L5637), test socket (L5620) multiple ply 
prosthetic sock (L8420), and single ply prosthetic sock (L8470) provided on October 14, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided the Plan does not have to pay for an X-ray scan of the knee (73564) provided on July 19, 2022.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan noted that it is not appropriate to report unspecified, left, right or bilateral diagnosis codes when the procedure modifier on the claim line does not match the diagnosis code. The only diagnosis code reported on this claim is M25.569 (pain in unspecified knee), which does not indicate the left side/knee as indicated by the modifier appended to code 73564.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. The records provided do not support the services billed on the claim. Medicare rules for payment of this clam were not met. Therefore, we decided that the Plan does not have to pay for an X-ray scan of the knee (73564) provided on July 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Kit sensor. 
 
You asked the Plan to pre-approve the FreeStyle Kit sensor. You say that you take Ozempic and it works with 
your FreeStyle Libre. You also say that you are unable to prick your finger for the OneTouch. The Plan denied 
your request. The Plan says you do not require insulin three or more times daily. 
 
 
 The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the FreeStyle Kit sensor. Our reviewer 
says that the CGM is not medically necessary. Our physician reviewer found you are not using insulin and do 
not have low blood glucose sugar so the CGM is not covered. Although the CGM has helped you control you 
blood glucose sugar, criteria for coverage are not 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 FreeStyle Kit sensor have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a FreeStyle Kit sensor.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for AlloSure on December 17, 2021, March 15, 2022, and June 20, 2022.
You asked the Plan to pay for this service. You say that this testing should be covered by the Plan. 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 and stated that Maximus did not apply the correct coverage criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for an AlloSure genetic testing. The Maximus Physician Reviewer determined that, since the goal of the provider is to keep tacrolimus levels low, it is reasonable to use AlloSure genetic testing by protocol. The Plan requested a reopen and stated that Maximus did not apply the correct LCD criteria. The medical records show the enrollee was a then 61-year-old woman with a history of end-stage renal disease, who underwent a kidney transplant on March 14, 2016. On March 15, 2022, the enrollee was assessed to have stage 2 chronic kidney disease.
The treatment plan was to continue immunosuppression with tacrolimus. The Plan is correct in this case. The documentation does not support that the coverage criteria established by LCD L38355 were met in this case, as the clinical information does not document clinical suspicion of rejection and a need to inform clinical decision-making about the necessity of renal biopsy at least 2 weeks post-transplant in conjunction with standard clinical assessment. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for AlloSure on December 17, 2021, March 15, 2022, and June 20, 2022.
Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve upgraded electronics. We decided that the Plan does not have to 
pre-approve seat lift feature.  
 
You asked the Plan to pre-approve the upgraded electronics and seat lift feature. You say that the components 
should be covered. The Plan says that the enrollee's upper limb strength and function are adequate to use the 
provided switches. The Plan also says the seat lift does not serve a medical purpose and cannot be covered. 
 
We decided that the Plan has to pre-approve upgraded electronics.  
 
The Plan follows Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or 
service, then that item or service will be covered when it is medically necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve upgraded electronics. Our reviewer says 
that upgraded electronics are medically necessary. Our physician reviewer found the complexity of the 
enrollee's 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, including, tilt, recline and elevating leg rests, via a joystick. 
Therefore, the reviewer found that the requested the upgraded electronics are 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 upgraded electronics and seat lift feature have been met. Therefore, we decided 
that the Plan has to pre-approve upgraded electronics.  
 
We also decided that the Plan does not have to pre-approve seat lift feature. 
 
The Plan follows Medicare rules. Medicare rules say that a power seat elevation feature is non-covered because 
they are not primarily medical in nature. Therefore, we decided that the Plan does not have to pre-approve seat 
lift feature. 
 
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 an expandable controller and electronic connection. 
 
You asked the Plan to pre-approve an expandable controller and electronic connection. You say that you want 
to appeal this denial. 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 an expandable controller and electronic 
connection. Our reviewer says that the requested expandable controller and electronic connection are not considered medically reasonable and necessary in this case. Our physician reviewer found the provided 
documentation indicates that the enrollee has adequate upper body function to operate standard power drives on 
a wheelchair. Therefore, the requested features 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 an expandable controller and electronic connection have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an expandable controller and electronic 
connection.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for inpatient hospital services provided from February 14, 2022, to February 24, 2022, at the Diagnosis Related Group (DRG) originally billed.
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that these services were reported appropriately and are supported as billed. The Plan denied your request. The Plan says that that the DRG submitted on this claim is not supported in the medical records.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. Our Medical director looked at the case file and the reopen request. At issue is payment for inpatient hospital services at the DRG originally billed. In this case, you billed the inpatient services provided with secondary diagnosis, J96.01, defined as Acute respiratory failure with hypoxia. Our Medical Director states that he clinical documentation supports a secondary diagnosis of Acute respiratory failure with hypoxia. Our Medical Director found that the enrollee's condition met Medicare criteria for the inpatient hospital services provided to the enrollee from February 14, 2022, through February 24, 2022, at the DRG originally billed. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for inpatient hospital services provided from February 14, 2022, to February 24, 2022, at the Diagnosis Related Group (DRG) originally billed.
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient psychiatric hospital care provided from 
December 26, 2022, through December 29, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the acute inpatient psychiatric hospital care 
provided was not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 these services. Our reviewer says that the 
acute inpatient psychiatric hospital care provided was not medically necessary. Our physician reviewer found 
that there was no indication in the available medical records that the enrollees psychiatric symptoms could not 
be managed on a less restrictive basis as of December 26, 2022. He was noted to have confusion at his baseline 
mental status. The enrollee was not exhibiting any other significant symptoms such as psychosis or mania. He 
had no acute psychiatric issues that would require continued inpatient care. The enrollee has chronic symptoms.  
The available medical records do not support that continued inpatient care would have changed these 
symptoms or the enrollees current condition. The enrollee is chronically impaired due to Major neurocognitive 
disorder and the continued inpatient hospital stay was not expected to improve the enrollees condition in a 
reasonable period of time. 
 
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 pay for the acute inpatient psychiatric hospital care provided from December 26, 2022, through 
December 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99204), an eye refraction (92015), fundus 
photography (92250), and gonioscopy (92020) provided on April 18, 2022, by an out-of-network (OON) 
provider.  
 You asked the Plan to pay for the vision services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says this provider is out-of-network. The services were not referred by a network 
provider or rendered in a participating facility. These services were not urgent or emergent, nor were they 
approved in advance. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit (99204), an eye refraction (92015), 
fundus photography (92250), and gonioscopy (92020) provided on April 18, 2022, by an out-of-network 
(OON) provider.