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

 
We decided that the Plan does not have to pay for procedure code A6248 billed for date of service February 17, 
2023. 
 
You asked the Plan to pay for the billed services. You say that the documentation supports the claim. The Plan 
denied your request. The Plan says the billed code cannot be verified. 
 
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 A6248 is hydrogel dressing, wound filler, gel, per fluid 
ounce. We find that CPT code A6248 is not supported in the medical record. There is a more accurate code that 
describes the services provided. 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 
A6248 billed for date of service February 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill (SSBCI).
You asked the Plan to pre-approve SSBCI benefits. You say that the provision related to the numbers of inpatient stays/emergency room visits is too restrictive when compared with the Social Security Act language. The Plan denied your request. The Plan says the criteria for eligibility have not been met. Maximus overturned the Plan's denial because they did not include the relevant EOC. The Plan has requested a reopening and now provided the 2023 Evidence of Coverage for review.
The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a documented chronic condition that is life threatening or significantly limits the health or function of the enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an eligible condition that meets all the required criteria. Your physician confirmed that you do not need intensive care management. Therefore, we decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for special supplemental benefits for the chronically ill (SSBCI).
You asked the Plan to pay for SSBCI benefits. You say that these services should be covered. The Plan denied your request. The Plan says that you are not eligible based on provider's response to attestation form.
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.
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 SSBCI benefits have been met. Your provider did not provide adequate documentation to confirm you have met the requirements for these benefits. Therefore, we decided that the Plan does not have to pay for special supplemental benefits for the chronically ill (SSBCI).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an insertion of non-tunneled centrally inserted central venous 
catheter (36556) and ultrasound guidance for vascular access requiring ultrasound evaluation of potential 
access sites (76937) provided on March 29, 2023. 
 
You asked the Plan to pay for an insertion of a venous catheter and an ultrasound guidance for vascular access. 
You say that you disagree with the denial and have submitted medical records for review. The Plan denied your 
request. The Plan says CPT codes 36556, 76937 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. 
 
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 insertion of a venous catheter and an ultrasound guidance for 
vascular access. Our reviewer says that the requested service does not meet criteria. Our reviewer found code 
36556 is not supported. The record does not state where the catheter terminated, which is a required element to 
report this code. Code 76937 is not supported. The record does not contain a description of vessel patency and 
possible access site for ultrasound guidance of vascular access. The record does not contain the required 
elements of the codes in question. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of insertion of a venous catheter and an ultrasound guidance for vascular access 
have not been met. Therefore, we decided that the Plan does not have to pay for an insertion of non-tunneled 
centrally inserted central venous catheter (36556) and ultrasound guidance for vascular access requiring 
ultrasound evaluation of potential access sites (76937) provided on March 29, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the primary care provider office visit provided on October 10, 2022.
You asked the Plan to waive the copayment for the primary care provider office visit. You say that you only had your blood pressure taken and were not seen by the provider. The Plan denied your request. The Plan says this cost sharing was charged correctly. Maximus overturned the Plan's denial. The Plan requested a reopening and provided the correct EOC.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 copayment for each Medicare-covered primary care visit.
You have been asked to pay a $30 copayment for the primary care provider office visit. This item/service falls within the Medicare-covered primary care visit benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the primary care provider office visit provided on October 10, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve the upgraded electronics (E2313, E2311, E2377).  
 
You asked the Plan to pre-approve the durable medical equipment (DME). You say that the enrollee meets the 
coverage criteria for the power wheelchair.  The Plan denied your request. The Plan says that there is not a 
medical need to control these power options through the joystick.  
 
The Plan must follow 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 the durable medical equipment (DME). 
Our reviewer says that the requested items/services are considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee is non-ambulatory and requires a power wheelchair for 
mobility and performing his basic daily activities. The enrollee cannot perform pressure relief independently 
due to upper extremity weakness and requires a power wheelchair with power tilt and recline for adequate 
pressure relief and positioning. The enrollee currently has a coccygeal pressure wound. The enrollee requires 
power elevating leg rests for positioning of their lower extremities and lower extremity spasticity and edema. 
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 via a joystick. These components are required to 
operate 3 or more power options on a group 3 power wheelchair. Therefore, the expandable controller (E2377) 
with harness (E2313) and electronic connection (E2311) is 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 the durable medical equipment (DME) have been met. Therefore, we decided 
that the Plan has to pre-approve the upgraded electronics (E2313, E2311, E2377).   
 
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental cleaning (D1110) provided on October 20, 2022.
You asked the Plan to pay for the dental cleaning. You say that you are requesting a reconsideration of the
Plan's denial for payment. The Plan denied your request. The Plan says your benefit for the requested item or
service has already been exhausted. Maximus overturned the Plan's denial for lack of documentation. The Plan
requested a reopening and provided additional Explanation of Benefit documents.
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 benefit for the requested item or service was exhausted on date of service June 23, 2022. Therefore,
we decided that the Plan does not have to pay for the dental cleaning (D1110) provided on October 20, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a Koya Dayspring System pneumatic compression device (K1024, K1033) for the enrollee.
You asked the Plan to pre-approve a Koya Dayspring System pneumatic compression device. You say that you disagree with the denial. The Plan denied your request. The Plan says that that the current peer-reviewed medical literature does not support that the requested Dayspring non-pneumatic compression device has been shown in controlled studies in a Medicare-approved journal to result in long-term health benefits for the treatment of lymphedema.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for a Koya Dayspring System pneumatic compression device. Our Medical Director states that the enrollee has persistent lower extremity edema. Results of clinical evaluation suggest that the Dayspring System active compression device is safe and effective and improves quality of life and limb volume. Our Medical Director found that the enrollee's condition meets criteria for coverage of a Koya Dayspring System pneumatic compression device. 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 Koya Dayspring System pneumatic compression device have been met. Therefore, we decided that the Plan has to pre-approve a Koya Dayspring System pneumatic compression device (K1024, K1033) for the enrollee.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Home Health
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve five (5) home health physical therapy visits (G0151 x5). We 
decided that the Plan does not have to pre-approve two (2) home health physical therapy visits (G0151 x2).  
 
You asked the Plan to pre-approve seven (7) home health physical therapy visits (G0151 x7). You say that the 
services are medically necessary. The Plan says that the services are not medically necessary. 
 
We decided that the Plan has to pre-approve five (5) home health physical therapy visits (G0151 x5).  
 
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 seven (7) home health physical therapy 
visits (G0151 x7). Our physician reviewer found five (5) visits is a very limited number for rehabilitation after 
a fall with trauma for a person with dementia. Ten (10) would be a usual standard. Additional therapy may be 
considered after 10 visits.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of five (5) home health physical therapy visits (G0151 x5) have been met. 
Therefore, we decided that the Plan has to pre-approve five (5) home health physical therapy visits (G0151 x5).  
 
We also decided that the Plan does not have to pre-approve two (2) home health physical therapy visits 
(G0151 x2). 
 
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 two (2) home health physical therapy 
visits (G0151 x2). Our physician reviewer found five (5) visits is a very limited number for rehabilitation after 
a fall with trauma for a person with dementia. Ten (10) would be a usual standard. Additional therapy may be 
considered after 10 visits.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of two (2) home health physical therapy visits (G0151 x2) have not been met. 
Therefore, we decided that the Plan does not have to pre-approve two (2) home health physical therapy visits 
(G0151 x2). 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac joint injection.  
You asked the Plan to pre-approve the injection. The Plan denied your request. The Plan says a sacroiliac joint 
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 the 
enrollee does not meet the LCD coverage criteria. Our physician reviewer found that the LCD requires three 
positive diagnostic test and only two were documented. There is also no documentation of conservative 
therapies that have been tried. 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 sacroiliac joint injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a powered upper extremity device (L8702). 
 
You asked the Plan to pre-approve the powered upper extremity device. You say that this device is medically 
necessary. The Plan denied your request. The Plan says 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 the powered upper extremity device. 
Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. 
Our physician reviewer found there is insufficient evidence in the literature that the MyoPro Orthosis will 
improve the long term outcomes for this patient. 
 
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 powered upper extremity device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a powered upper extremity device (L8702).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that you are appealing the denial 
of coverage for the Flexitouch pneumatic compression pump prescribed to treat lymphedema The Plan denied 
your request. The Plan says the enrollee does not meet the LCD criteria for an advanced lymphedema pump as 
there is no failed four-week trial of a basic pneumatic compression device of either E0650 or E0651. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided.  Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block.  
 
You asked the Plan to pre-approve a genicular nerve block. You say that this particular procedure was 
recommended by your doctor because a lot of people have stated it works. You say that if you cannot have this 
procedure your next option would be a knee replacement and that is what you are trying to prevent. The Plan 
denied your request. The Plan says the requested genicular nerve block is experimental and investigational due 
to a lack of scientific evidence regarding the effectiveness of a genicular nerve block for the knee. 
 
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 genicular nerve block. Our reviewer 
says that the requested genicular nerve block is not considered medically reasonable and necessary in this case. 
Our physician reviewer found that this procedure is considered experimental/investigational. It is the subject of ongoing clinical trials. Therefore, the request is deemed 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 a genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a genicular nerve block.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiological services provided on February 13, 2023, billed 
with procedure codes 74230, 74240, 72040, 70100, 70310, and 71045. 
 
You asked the Plan to pay for the radiology services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says this is a non-covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that procedures requiring the administration of a 
substance to the patient or injection of a substance into the patient and/or special manipulation of the patient are 
not covered under portable x-ray provision.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the radiology services provided have not been met. The service provided is a barium swallow study 
and includes the administration of a substance to the patient. As such, this is a non-covered service. Therefore, 
we decided that the Plan does not have to pay for radiological services provided on February 13, 2023, billed 
with procedure codes 74230, 74240, 72040, 70100, 70310, and 71045.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a retainer crown for teeth #11 and #6 and pontic for 
teeth #10, 7, 8, and 9 (D6245, D6790). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as you do 
not meet the clinical requirements to be approved. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the dental 
services when the services are medically necessary and reasonable.  
 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the dental services. Our physician 
reviewer found that the enrollee does not meet the clinical requirements for a retainer crown or pontic. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a retainer crown for teeth #11 and #6 and pontic for teeth #10, 7, 8, and 9 (D6245, 
D6790).