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

 
We decided that the Plan does not have to pre-approve  a group 3 power wheelchair and accessories. 
 
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied 
your request. The Plan says the current wheelchair, with manual tilt and custom seating, is appropriate to meet 
the enrollee's needs. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 wheelchair. Our reviewer says that 
the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found that in this 
case, the documentation available for review does not support that the enrollee requires a power mobility 
device to accomplish mobility related self-care tasks in the home.  There is no indication they are unable to use 
an alternative assistive device with caregiver support available at the facility where she resides. Additionally, 
there is not an appropriate diagnosis to meet criteria for a group 3 power wheelchair. 
 
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 wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve  a group 3 power wheelchair and accessories.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0651, E0667). 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not show a documented clinical response to initial treatment with the 
device. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee has lymphedema secondary to chronic venous insufficiency. There are no ulcers. This is 
not medically necessary in the absence of ulcers, and when lymphedema is secondary to chronic venous 
insufficiency. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a pneumatic compression device (E0651, E0667).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gemtesa. 
 
You asked the Plan to pre-approve the medication. You say that due to the enrollee's diagnosis of hypertension, 
age (increased risk for cognitive decline), and large medication list (with potential interactions), you do not 
recommend a trial of anticholinergics. 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 Gemtesa.  
 
Benefits for the medication 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: Inpatient Hospital
Decision: Unfavorable

We decided the Plan does not have to pay for post stabilization inpatient care provided to the enrollee from May 31, 2023, through June 1, 2023. 

You asked the Plan to pay post stabilization care. The Plan denied full payment. The Plan says service provided after May 30, 2023, were not necessary as at that point the enrollee was stable for transfer to a par facility. Maximus partially overturned the Plans denial. The Plan requested a reopen and noted that Maximus basically agreed with the Plan. 

The Plan is correct in this case. At issue is the request for post stabilization care after May 30, 2023. Our physician reviewer found post-stabilization care services means covered services, related to an emergency medical condition, that are provided after an enrollee is stabilized to maintain the stabilized condition, or to improve or resolve the enrollee's condition. The physician treating the enrollee must decide when the enrollee may be considered stabilized for transfer or discharge. The medical records show all inpatient care provided after May 30, 2023, was not needed on an emergent basis. The treating physician did not document (in the physician notes, on a form, or in an order) that the enrollee was not stable for transfer. Therefore, Medicare criteria for post stabilization care were no longer met after May 30, 2023. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of services provided on May 31, 2023, June 1, 2023, were not met. Therefore, we decided that the Plan does not have to pay for post stabilization inpatient care provided to the enrollee from May 31, 2023, to June 1, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug services (J7799) provided on March 15, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for out-of-network drug services. You say that these services were billed 
appropriately for payment. The Plan denied your request. The Plan says these services were not provided by or 
referred by a network provider. Out-of-network care is covered only in certain limited circumstances, which 
have not been met in this case. 
 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 drug services (J7799) provided on March 15, 
2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve block (64454). 
 
You asked the Plan to pre-approve genicular nerve block. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have 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 genicular nerve block. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found genicular nerve block is experimental for knee pain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve genicular nerve block (64454).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on August 02, 2023. 
 
You asked the Plan to pay for psychotherapy. You say that the services were medically necessary. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for psychotherapy provided 
on August 02, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services described by code 00811-PT 
performed on date of service June 9, 2023. 
 
You asked the Plan to pay for 00811-PT. You say that 00811-PT should be paid as billed because it is coded 
correctly and is supported in the documentation. The Plan denied your request. The Plan says 00811-PT is 
denied because it is incorrectly coded. 
 
The Plan must follow Medicare rules. Medicare rules say that when a screening colonoscopy becomes a 
diagnostic colonoscopy, anesthesia services are reported with CPT code 00811 and with the -PT modifier.  
 
We looked at the file and Medicare rules. In this case, the case file contains no evidence that the colonoscopy 
performed in conjunction with the anesthesia services coded as 00811-PT was planned as a screening service. 
In fact, the evidence suggests that the colonoscopy was done due to symptoms including change in bowel habits, constipation, and lower abdominal pain. Per Medicare rules, modifier -PT is only used when a 
colonoscopy begins as a screening and then becomes a diagnostic colonoscopy. As such, the use of modifier -
PT is not supported. Based on this information, we decided that Medicare rules for coverage of 00811-PT have 
not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services described by 
code 00811-PT performed on date of service June 9, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound of the abdominal aorta (76706) provided on 
August 18, 2023. 
 
You asked the Plan to pay for the ultrasound. You say that the service was billed correctly and should be paid. 
The Plan denied your request. The Plan says that the records provided does not support coverage under 
Medicare criteria for this type of screening as the records document a previous AAA exam performed on 
4/2/18. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare covers a one-time screening for AAA 
for beneficiaries who meet certain criteria.   
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the AAA screening have not been met. Specifically, there is a one-time payment for ultrasound 
screening for abdominal aortic aneurysm (AAA) for beneficiaries who have a family history of abdominal 
aortic aneurysm, are a man between age 65 and 75 who has smoked at least 100 cigarettes in his lifetime or is a 
beneficiary who manifests other risk factors in a beneficiary category recommended for screening by the 
United States Preventive Services Task Force regarding AAA. Medical records document that the screening for 
AAA was provided in 2018. Since this testing was already provided once for this enrollee, no further 
screenings are covered. Based on this information, we decided that Medicare rules for coverage of the 
ultrasound have not been met. Therefore, we decided that the Plan does not have to pay for the ultrasound of 
the abdominal aorta (76706) provided on August 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray and laboratory services provided on June 09, 2023. 
 
You asked the Plan to pay for an x-ray and laboratory services. You say that this was medically necessary and 
should be covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an x-ray and laboratory 
services provided on June 09, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on August 12, 2023. 
 
You asked the Plan to pay for a home visit. You say that the services were medically necessary. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a home visit provided on 
August 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS device. 
 
You asked the Plan to pre-approve the CardioMEMS device. You say that you are appealing the denial. The 
Plan denied your request. The Plan says that there are not enough studies to support the use of CardioMEMS 
over other types of treatment. 
 
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 CardioMEMS device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there remains a dearth of randomized, blinded clinical studies examining long-
term clinical outcomes establishing the value of CardioMEMS in patient management. As a result, at this time 
the CardioMEMS system would not be considered medically appropriate and necessary in this enrollee's 
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 CardioMEMS device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the CardioMEMS device.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the pembrolizumab injection and the drug 
administration provided on July 6, 2023. 
 
You asked the Plan to waive the coinsurance for the injection and drug administration. You say that you had 
the same services in May and the Plan paid more on that claim. 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for each in-network Medicare-covered chemotherapy drug and the administration of that drug.  
 
 You have been asked to pay $4,384.88, which is 20% coinsurance of the allowed amount for the injection 
($21,924.40 allowed amount x 20% coinsurance = $4,384.88). You have also been asked to pay $62.66, which 
is 20% coinsurance of the allowed amount for the drug administration ($313.28 allowed amount x 20% 
coinsurance = $62.66). You have been asked to pay a total of $4,447.54 ($4,383.88 + $62.66 = $4,447.54). 
These services fall within the Medicare Part B prescription drugs 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 coinsurance for the pembrolizumab injection and the drug administration provided on July 6, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for remote monitoring services provided on August 11, 2023. 
 
You asked the Plan to pay for remote monitoring services. You say that this was medically necessary and 
should be covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for remote monitoring 
services provided on August 11, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS device. 
 
You asked the Plan to pre-approve a CardioMEMS device. You say that this is medically necessary for the 
enrollee's condition. 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 a CardioMEMS device. 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 Food and Drug Administration (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 congestive heart failure (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 device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS device.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Ozempic (C9399). 
 
You asked the Plan to pre-approve Ozempic. You say that the requested drug is a medical necessity for the 
enrollee. 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 drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Ozempic 
(C9399).  
 
Benefits for Ozempic 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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Supartz FX. 
 You asked the Plan to pre-approve Supartz FX. You say that you are requesting reconsideration for the denial 
of Supartz. You say you only carry Supartz in house. The Plan denied your request. The Plan says step therapy 
requirements have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Supartz FX. Our reviewer says that the 
criteria for coverage of Supartz FX have not been met. Our physician reviewer found step therapy, as outlined 
by the Plan, requires that one of the preferred viscosupplemental treatments, Monovisc, Orthovisc or 
Synvisc/Synvisc-One, be trialed first. The documentation does not outline contraindications or reasons these 
medications were not considered or that the Plan's additional required drugs would likely be less effective or 
likely have adverse effects for the enrollee. Without the support of the documentation, Supartz FX is not 
approved as step criteria have not been 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 Supartz FX have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Supartz FX.