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

 
We decided that the Plan does not have to pay for EsoGuard testing provided on June 21, 2023. 
 You asked the Plan to pay for EsoGuard testing. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says screening services are not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, EsoGuard testing, was requested solely for screening purposes. Medicare does 
not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for 
EsoGuard testing provided on June 21, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a prosthetic leg with an electronic knee feature
(L5828, L5845, L5848, L5856, L5694, L5988, L5984).

You asked the Plan to provide coverage for this prosthetic equipment. 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 criteria. The Plan noted you had previously been
approved for an initial above knee open end sach foot prosthesis. This is a prosthesis commonly used by K2
above knee amputees, as this member is noted to be. The vendor has requested a new above knee prosthesis
with microprocessor knee shin system. Your physician offers no objective clinical evidence to support the need
of a microprocessor knee. The medical records do not show why a mechanical K3 knee would not be
appropriate. The physician's notes do not show why a mechanical knee cannot be used for your prosthesis,
especially given the weight a microprocessor knee, need for increased maintenance and increased susceptibility
to corrosion and water damage. The requested microprocessor knee exceeds your medical need. The requested
L5988 Shock Reducing Pylon also exceeds your needs. The medical records from your physician do not
indicate high impact activities that would require a shock reducing pylon.

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. Medicare has specific coverage criteria for the prosthetic components
requested. 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. Therefore, we decided that the Plan does not have to provide coverage for a prosthetic leg with
an electronic knee feature (L5828, L5845, L5848, L5856, L5694, L5988, L5984).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from April 17, 2023, to April 
28, 2023. 
 You asked the Plan to pay for home health services. You say that you have billed the services at issue correctly. 
The Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied. 
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the NOA (type of bill 032A) was not received by the Plan. Consequently, no payment can be made 
on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided from 
April 17, 2023, to April 28, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on June 5, 2023, to June 30, 
2023. 
 
You asked the Plan to pay for home health services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the provider did not bill as required by Medicare coding regulations. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the home health services have not been met. The claim was billed 
with an invalid type of bill. We find the Medicare rule for payment of this June 5, 2023, through June 30, 2023, 
claim has not been met. Therefore, we decided that the Plan does not have to pay for home health services 
provided on June 5, 2023, to June 30, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom wheelchair ramp (E1399). 
 
You asked the Plan to pre-approve a custom wheelchair ramp. You say that this item is medically necessary. 
The Plan denied your request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a custom wheelchair ramp (E1399).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting admission to this facility for 
intensive therapy to be able to safely and independently care for yourself. The Plan denied your request. The 
Plan says the inpatient rehabilitation facility (IRF) services you are requesting do not meet the requirements for 
approval.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for lumbar spine surgery. Medical problems are stable. The enrollee does not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While the medical record supports a need for physical and/or occupational therapy, there is 
no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the EsoGuard testing (0114U) provided on June 20, 2023. 
 You asked the Plan to pay for the EsoGuard testing. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says screening tests are not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the EsoGuard testing, was requested solely for screening purposes. Medicare 
does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay 
for the EsoGuard testing (0114U) provided on June 20, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 14, 2023, billed with 
codes  81227, 81231, 81232 and 81328. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim.  
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
March 14, 2023, billed with codes  81227, 81231, 81232 and 81328.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zeposia. 
 
You asked the Plan to pre-approve Zeposia. You say that this is medically necessary. The Plan denied your 
request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Zeposia.   
Benefits for Zeposia may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 standard power wheelchair with single power 
option (K0856). 
 
You asked the Plan to pre-approve a Group 3 standard power wheelchair. You say that a group 3 single power 
wheelchair with power tilt and articulating foot platform would be the best option for the enrollee. The Plan 
denied your request. The Plan says the enrollee does not have medical need for single power option included 
with K0856 group 3 power wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 PWC with single power option (such as 
code K0856) is covered if the criteria listed in the Medicare rules section of this letter 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 a Group 3 standard power wheelchair. 
Our reviewer says that the group 3 power wheelchair with power tilt and power elevating leg rests is not 
medically necessary. Our physician reviewer found the enrollee requires a power wheelchair for mobility and 
accomplishing their daily activities. However, the clinical documentation is insufficient why a lower-level 
power wheelchair would not meet the enrollees needs versus a group 3 power wheelchair. Our reviewer found 
that there is inadequate clinical documentation regarding why they require power tilt and cannot adequately 
perform pressure relief. Our physician reviewer also found that there is no history of skin breakdown and they 
do not have a significant risk for skin breakdown. A group 3 power wheelchair base is typically indicated in 
patients with significant paralysis due to conditions such as a spinal cord injury. 
 
 
 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 Group 3 standard power wheelchair have not been met. The records show that 
the original request for the Group 3 power wheelchair with single power option used the code K0858. This 
code is defined as Group 3 heavy duty power wheelchair, single power option, sling/solid seat/back, patient 
weight 301 to 450 pounds. The records show that the enrollee weighs 290 pounds. Thus, code K0858 was not 
the appropriate code to represent the type of Group 3 power wheelchair with single power option. Hence, the 
Plan reviewed the request for this item under code K0856 which is defined as Group 3 standard power 
wheelchair, single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds. 
Therefore, we decided that the Plan does not have to pre-approve a Group 3 standard power wheelchair with 
single power option (K0856).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel provided on 
May 31, 2023, and billed with codes 87481, 87500, 87640, 87798, and 87652. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the urine PCR panel have not been met. 
Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel 
provided on May 31, 2023, and billed with codes 87481, 87500, 87640, 87798, and 87652.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Barostim Neo system (0266T, C1825). 
 
You asked the Plan to pre-approve Barostim Neo system. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says this is experimental and therefore is not covered. 
 
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 Barostim Neo system. Our reviewer 
says that the requested Barostim Neo system is not considered medically reasonable and necessary in this case. 
Our physician reviewer found There remains an absence of randomized, blinded clinical studies examining 
long-term clinical outcomes establishing the value of Barostim Neo in patient management. Therefore, the 
reviewer found that the requested Barostim Neo is 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 Barostim Neo system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Barostim Neo system (0266T, C1825).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve esophagogastroduodenoscopy (EGD) (43235). 
 
You asked the Plan to pre-approve a repeat EGD. You say that you do not agree with this denial. The Plan 
denied your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a repeat EGD. Our reviewer says that 
the requested repeat EGD is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the provided documentation indicates the enrollee has no significant ongoing upper 
gastrointestinal (GI) symptoms, does not warrant esophageal dilation nor Barrett's surveillance, and the time 
frame for Barrett's screening is not met at this time. Therefore, the reviewer found that the requested repeat 
EGD is not 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 a repeat EGD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve esophagogastroduodenoscopy (EGD) (43235).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the office visit provided by an out-of-
network provider on May 3, 2023, and the dexamethasone sodium phosphate injection, and the injection 
performed with image guidance provided by an out-of-network provider on May 18, 2023. 
 
You asked the Plan to waive the deductible for the office visit, and the injection services. You say that you 
were not informed that the provider was out-of-network. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $750 deductible which applies to the out-of-network office visit, and 
the injection services.  
 
 
 
 
 You have been asked to pay a $541.96 deductible for the office visit and the injection services. The items or 
services you asked the Plan to waive the deductible for were provided by an out-of-network provider. The Plan 
has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible which applies 
to Medicare Part B prescription drugs, and physician/practitioner services, including doctors office visits. This 
cost sharing is a contractual obligation that had not been met at the time the office visit, and the injection 
services were received on May 3, 2023, and May 18, 2023. Therefore, we decided that the Plan does not have 
to waive the deductible for the office visit provided by an out-of-network provider on May 3, 2023, and the 
dexamethasone sodium phosphate injection, and the injection performed with image guidance provided by an 
out-of-network provider on May 18, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a group 2 heavy duty power wheelchair (K0825) and two 22nf 
sealed lead acid batteries (E2361 x2). 
 
You asked the Plan to pre-approve a group 2 heavy duty power wheelchair and two 22nf sealed lead acid 
batteries. You say that you would like a power wheelchair to be approved for the patient. The Plan denied your 
request. The Plan says that the patient does not meet the medical necessity for a powered wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will be covered if the patient has a mobility 
deficit that impairs their participation in MRADLs, the patients condition cannot be ameliorated by a walker, 
cane or manual wheelchair, and the patient is capable of safely operating the requested PMD.  
 
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 group 2 heavy duty power wheelchair 
and two 22nf sealed lead acid batteries. Our reviewer says that the group 2 power wheelchair and accessories 
are medically necessary. Our physician reviewer found the patient is functionally non-ambulatory and cannot 
use a cane or walker for mobility. They can only walk short distances in the home. The patient cannot 
functionally propel a manual wheelchair due to lack of upper extremity endurance, limited shoulder range of 
motion and shortness of breath due to chronic obstructive pulmonary disease (COPD). Our reviewer found that 
the patient requires a power wheelchair for mobility and accomplishing their daily activities. The patients 
home will not accommodate a power scooter and the turning radius required to operate it. Our physician 
reviewer also found that the patient has undergone a power mobility evaluation and their home is accessible. 
 
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 group 2 heavy duty power wheelchair and two 22nf sealed lead acid batteries 
have been met. Therefore, we decided that the Plan has to pre-approve a group 2 heavy duty power wheelchair 
(K0825) and two 22nf sealed lead acid batteries (E2361 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450-26 billed for date of service May 18, 
2023. 
 You asked the Plan to pay for procedure code 70450-26. You say that you added the XS modifier to identify 
this code as a separate and distinct procedure. The Plan denied your request. The Plan says payment for code 
70450-26 is bundled into payment for code 70496-26. 
 
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 
70450-26 is a column II code to column I code 70496-26. This claim has not been billed with an appropriate 
modifier to bypass the edit. Although you contend that this code was billed with the XS modifier, no such 
modifier is present on the claim submitted. 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 70450-26 billed for date 
of service May 18, 2023.