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

 
We decided that the Plan does not have to pre-approve transthoracic echocardiography (TTE) (93306) to be 
provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve TTE with an out-of-network provider. You say that this is medically 
necessary. The Plan denied your request. The Plan says the service is available in-network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
   
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
transthoracic echocardiography (TTE) (93306) to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a retainer crown (D6751), and a pontic (D6241). 
 
You asked the Plan to pay for D6751 and D6241. You say that you need this dental work. The Plan denied your 
request. The Plan says the denied dental services are not covered benefits. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a retainer 
crown (D6751), and a pontic (D6241).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76000 billed for date of service October 12, 
2022, to October 13, 2022. 
 
You asked the Plan to pay for procedure code 76000. You say that these services were necessary and were 
reported appropriately. The Plan denied your request. The Plan says payment for code 76000 is bundled into 
payment for code 63047. 
 
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 76000 
is a column II code to column I code 63047. This claim has not been billed with an appropriate modifier 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 76000 billed for date of service October 12, 
2022, to October 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve expandable controller identified with code E2377, 
harness for upgrade to expandable controller identified with code E2313, electronic connection between 
wheelchair controller and two or more power seating system motors identified with code E2311. 
 
You asked the Plan to pre-approve expandable controller, harness for upgrade to expandable controller, 
electronic connection between wheelchair controller and two or more power seating system motors. You say 
that you disagree with the Plan's denial. The Plan denied your request. The Plan says the requested items are 
not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that power wheelchair accessories are only covered 
for certain indications.  
 
We looked at the file and Medicare rules. Review of the file shows that there is no medical need to control the 
power options through the joystick. The documentation specifically states that the enrollee is independent with 
the use of switches. The enrollees upper limb strength and function are adequate for the enrollee to be able to 
control the power options using their own switches which are included in the allowance of the approved power 
options. Based on this information, we decided that Medicare rules for coverage of expandable controller, 
harness for upgrade to expandable controller, electronic connection between wheelchair controller and two or 
more power seating system motors have not been met. Therefore, we decided that the Plan does not have to 
pre-approve expandable controller identified with code E2377, harness for upgrade to expandable controller 
identified with code E2313, electronic connection between wheelchair controller and two or more power 
seating system motors identified with code E2311.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an orientation wedge and a pelvic obliquity kit hardware 
(K0108x2). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that the requested accessories are 
medically necessary for the enrollee to be able to be independent. The Plan denied your request. The Plan says 
the enrollee does not meet criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say wheelchair seat and back cushion codes are all-
inclusive.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of wheelchair accessories have not been met. Specifically, the orientation wedges and the pelvic 
obliquity are already included with the approved cushions and cannot be requested separately. Therefore, we 
decided that the Plan does not have to pre-approve an orientation wedge and a pelvic obliquity kit hardware 
(K0108x2).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87081 provided on March 16, 2023. 
 
You asked the Plan to pay for procedure code 87081. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not supported. 
 
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 procedure code 87081 have been met. 
We find that CPT code 87081 is not supported in the medical record. The documentation provided does not 
include lab results to show that the services were rendered by the billing provider. Therefore, we decided that 
the Plan does not have to pay for procedure code 87081 provided on March 16, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.  
 
You asked the Plan to pre-approve the PET scan. You say that this is medically necessary. The Plan denied 
your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the documentation does not show testing 
for the cognitive decline. This enrollee has a presumptive diagnosis of Alzheimers dementia or Lewy body 
dementia. Based on review of the documentation and the criteria for coverage of a PET scan, this enrollee does 
not meet the criteria put forth by the Medicare National Coverage Determination center as this enrollee has not 
had the cognitive testing and is a presumptive diagnosis. 
 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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve the requested power wheelchair modifications/accessories 
(K0108). 
 
You asked the Plan to pre-approve the requested power wheelchair modifications/accessories (K0108). You 
say that the requested power wheelchair modifications/accessories are medically necessary. The Plan denied 
your request. The Plan says that the services are not covered. 
 
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 requested power wheelchair 
modifications/accessories. Our reviewer says that the requested power wheelchair modifications/accessories are 
medically necessary. Our physician reviewer found the enrollee has severe Amyotrophic lateral sclerosis (ALS) 
and essentially only able to move her head. She requires alternate methods of managing her wheelchair. She is 
on a ventilator and has no voice. She has no body control. The plan has denied these devices as miscoded. The 
provider has submitted medical rationale for the accessories. The requested modifications/accessories are 
medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Please note that the Plan's coding guidelines 
as a reason to deny the requested items is incorrect. The provider has requested modifications to the approved 
accessories, which would be coded as K0108 correctly in this case. Based on this information, we decided that 
Medicare rules for coverage of the requested power wheelchair modifications/accessories have been met. 
Therefore, we decided that the Plan has to pre-approve the requested power wheelchair 
modifications/accessories (K0108).  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Barostim Neo device (0266T, C1825). 
 
You asked the Plan to pre-approve the Barostim Neo device. You say that this is medically necessary. The Plan 
denied your request. The Plan says Barostim Neo is considered investigational and cannot be approved. 
 
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 Barostim Neo device. Our reviewer 
says that there remains an absence of randomized, blinded clinical studies examining long-term clinical 
outcomes establishing the value of Barostim Neo in patient management. Our physician reviewer found at this 
time, the Barostim Neo 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 the Barostim Neo device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Barostim Neo device (0266T, C1825).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (87150) provided to the enrollee on July 5, 2022.

You asked the Plan to pay for code 87150. The Plan denied your request. The Plan says the records provided
do not support the billing of this code. Maximus overturned the Plans denial. The Plan requested a reopen and
stated that Maximus did not apply the correct criteria. The Plan noted the lab report includes documentation
regarding the methodology (PCR) for the assay panel performed but does not describe culture and typing by
nucleic acid probe.

There is one report submitted for review and no results are provided for code 87150. The medical records
submitted with the claim do not indicate that the service provided included testing outside of the panel codes
billed. The methodology does not specify that this test was for "detection by nucleic acid."

The Plan is correct in this case. 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 code 87150 were met. Therefore, we decided that the Plan does not have to pay for lab
services (87150) provided to the enrollee on July 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a porcelain crown (D2751) for teeth numbers 13, 14, 15 and 
30 provided from May 2, 2023, to June 15, 2023.  
 
You asked the Plan to pay for the dental services. You say that before you began treatment, you were told by 
someone that you would be reimbursed for these services. The Plan denied your request. The Plan says the 
dental services were received from an out-of-network provider and are not covered by your supplemental 
benefits.  
 
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 record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a porcelain crown (D2751) for teeth numbers 13, 14, 15 and 30 provided from May 2, 2023, to June 
15, 2023.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve endovascular repair of infrarenal aorta and/or iliac artery(ies) 
(34705), and open femoral artery exposure for delivery of endovascular prosthesis (34812). 
 
You asked the Plan to pre-approve endovascular repair of infrarenal aorta and/or iliac artery(ies), and open 
femoral artery exposure for delivery of endovascular prosthesis. You say that this is medically necessary. The 
Plan denied your request. The Plan says that this is not medically necessary because the records show the 
enrollee does not have a symptomatic, saccular or leaking abdominal aortic aneurysm (AAA), an AAA 5.5 
centimeters or larger, or that the enrollee's AAA has increased in size by 1 centimeter in 12 months or 0.5 
centimeters in 6 months. In addition, a literature search shows that 2 centimeter is a normal aorta size. 
 
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 endovascular repair of infrarenal aorta 
and/or iliac artery(ies), and open femoral artery exposure for delivery of endovascular prosthesis. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found while guidelines might provide a general recommendation of waiting for a AAA to 
be 5.5 centimeters or greater, these are guidelines and are not absolutes and can be tailored to an individual 
patient. The surgeon in this case believes the aneurysm is relatively large as compared to his native aorta 
suggesting a higher risk for rupture than the same size aneurysm in a larger native aorta. Additionally, the 
enrollee had recent abdominal surgery that may theoretically increase the risk of rupture. In summary the 
aneurysm is within 5 millimeters of vascular society guidelines, and within the size for which treatment is both 
reasonable and 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 endovascular repair of infrarenal aorta and/or iliac artery(ies), and open femoral 
artery exposure for delivery of endovascular prosthesis have been met. Therefore, we decided that the Plan has 
to pre-approve endovascular repair of infrarenal aorta and/or iliac artery(ies) (34705), and open femoral artery 
exposure for delivery of endovascular prosthesis (34812).  
 
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 pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you need this level of care. The Plan 
denied your request. The Plan says medical records do not support the need for an LTACH admission and, your 
needs can be managed at the current facility. 
 
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 you are receiving appropriate care in your current acute care setting. The 
documentation does not support that LTACH services are medically recommended at this 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit. 
 
You asked the Plan to pre-approve an office visit. You say that you were approved on July 12, 2023, and have 
been waiting to use it, however now your being told you are not approved, and it has made you very confused. 
The Plan denied your request. The Plan says that the only covered chiropractic service is manual manipulation 
of the spine. 
 
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 service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pre-approve an office visit.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from November 10, 2023, 
forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from November 10, 2023, forward. You say that 
the services at issue were medically necessary. The Plan denied your request. The Plan says the services at 
issue were 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 pre-approve inpatient psychiatric care from 
November 10, 2023, forward. Our reviewer says that the enrollee does not meet the criteria for treatment in an 
acute inpatient mental health treatment beyond the date in question of November 10, 2023, forward. Our 
physician reviewer found the enrollee did not require inpatient mental health treatment beyond November 10, 
2023, as she was not a danger to herself or others and did not have any delusions, auditory or visual 
hallucinations. It did not appear that active treatment was taking place beyond the date in question. It did not 
appear that the services for the dates in question were reasonably expected or medically necessary to improve 
the enrollees condition or for the purpose of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from November 10, 2023, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from November 10, 
2023, forward.