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

 
We decided that the Plan does not have to pre-approve bone marrow aspirate (20939). 
 
You asked the Plan to pre-approve bone marrow aspirate. 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 bone marrow aspirate. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found bone marrow aspirate is experimental when used as bone graft material in spine surgery. More research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate (20939).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection for a power wheelchair. 
 
You asked the Plan to pre-approve the requested item. You say that when a power function is provided, an 
electronic connection is allowed. The Plan denied your request. The Plan says the power options can be 
controlled using their own switches. 
 
The Plan follows Medicare rules. Medicare rules say that wheelchair items and accessories are only covered 
under certain medical indications. 
 
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 item. Our physician 
reviewer found that the enrollee has 4 out of 5 to 5 out of 5 bilateral upper extremity strength (as measured by a 
physical medicine and rehabilitation specialist). He is reported to be independent with feeding and grooming. 
These records overall support that the enrollee has adequate upper extremity strength and function to operate 
the wheelchair's power options with their own switches. Therefore, the request 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 the requested item have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an electronic connection for a power wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a supply allowance for non-adjunctive, non-implanted 
continuous glucose monitor (CGM) (A4239) and a non-adjunctive, non-implanted continuous glucose monitor 
or receiver (E2103). 
 
You asked the Plan to pre-approve non-adjunctive, non-implanted CGM monitor and/or receiver. You say that 
you are diabetic, and you need additional supplies. The Plan denied your request. The Plan says the information 
shows that you are not taking insulin for your diabetes. You are not having problems with severe low blood 
sugar events either. 
 
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 non-adjunctive, non-implanted CGM 
monitor and/or receiver. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the review indicates that you have diabetes 
but is not maintained on insulin therapy. The review has also determined that you do not meet criteria for a 
non-adjunctive CGM. The requested CGM 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 non-adjunctive, non-implanted CGM monitor and/or receiver have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a supply allowance for non-adjunctive, 
non-implanted continuous glucose monitor (CGM) (A4239) and a non-adjunctive, non-implanted continuous 
glucose monitor or receiver (E2103).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the localized delivery of antimicrobial agents via a controlled 
release vehicle into diseased crevicular tissue, per tooth (D4381) provided on May 18, 2023.  
 
You asked the Plan to pay for dental services. You say that your provider is in-network so the services should 
be covered. The Plan denied your request. The Plan says this service is not covered under your Plan. 
 
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 item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per 
tooth (D4381) provided on May 18, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that  the enrollee is unable to walk and has chronic 
weakness present since the last hospital admission has not recently changed. The Plan says the enrollee was 
discharged from rehabilitation the same day returned to the hospital due to the inability to ambulate. The Plan 
denied your request. The Plan says the enrollee does not require a skilled therapist to provide daily hands-on 
care for mobility or activities of daily living. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the upgraded electronics and attendant control. 
 
You asked the Plan to pre-approve the upgraded electronics and attendant control. You say that this power 
wheelchair and all of the recommended components are necessary to meet the enrollee's mobility, medical and 
functional needs in their home. The Plan denied your request. The Plan says an attendant control cannot be 
provided in addition to a beneficiary-operated drive control system. The Plan also 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 items and services that are not medically 
necessary are not covered. The rules also say that an attendant control, when provided with a beneficiary-
operated drive control system, is non-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 upgraded electronics and attendant 
control. Our reviewer says that the requested upgraded electronics are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the provided records indicate that the enrollee has 
adequate upper body strength to manage standard power drives. Therefore, the reviewer found that the 
requested upgraded electronics are not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the upgraded electronics and attendant control have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the upgraded electronics and attendant control.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power wheelchair accessories. 
 
You asked the Plan to pre-approve the requested service. You say that the items are medically necessary. The 
Plan denied your request. The Plan says the enrollee does not need to control the approved power options 
through a joystick. 
 
The Plan follows Medicare rules. Medicare rules say that power wheelchair items and accessories are only 
covered under certain medical indications. 
 
The file shows that an electronic connection was requested. 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 service. Our physician reviewer found that the enrollee has 3 out of 5 
bilateral upper extremity strength (as measured by physical therapy) and 4 out of 5 bilateral upper extremity 
strength (as measured by neurology) with no tremor. She has upper extremity/hand/wrist range of motion 
reported as within normal limits and unspecified limited upper extremity function. These records overall 
support that the enrollee has adequate upper extremity strength and function to operate the wheelchairs power 
options with their own switches. Therefore, the electronic connection is not medically necessary.  
 
The file shows that a lateral positioning wedge (code K0108) was requested. Use of HCPCS code K0108 or 
any other HCPCS code to separately bill for added components such as the foam blocks, gel packs, air cells, or 
equivalent material is incorrect coding.  
 
The file shows that a privacy flap was requested. An option/accessory that is beneficial primarily in allowing 
the beneficiary to perform leisure or recreational activities is non-covered.  
 
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 requested service have not been met. Therefore, we decided that the Plan 
does not have to pre-approve power wheelchair accessories.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an addition to lower limb prosthesis, vacuum pump, 
residual limb volume management and moisture evacuation system (L5781). 
 
You asked the Plan to pre-approve an addition to lower limb prosthesis. You say that the enrollee needs the 
requested prosthetic due to current prosthetic limb becoming a hazard (ill fitting) and prone to falls. The Plan 
denied your request. The Plan says Medicare guidance says that experimental items and items that are not 
shown to be safe and effective cannot be covered. Therefore, that requested vacuum socket cannot be 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 an addition to lower limb prosthesis. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found provided medical records from the treating/prescribing physician in 
this case do not document necessity of the Vacuum Assisted Socket System (VASS). As stated in the Local 
Coverage Article: Standard Documentation Requirements for All Claims Submitted to Durable Medical 
Equipment (DME) - A55426: "Supplier-produced records, even if signed by the treating practitioner, and 
attestation letters (e.g., letters of medical necessity) are deemed not to be part of a medical record for Medicare 
payment purposes. A prescription is not considered to be part of the medical record. Medical information 
intended to demonstrate compliance with coverage criteria may be included on the prescription but must be 
corroborated by information contained in the medical record. The enrollees medical record must contain 
sufficient documentation of the enrollees medical condition to substantiate the necessity for the type and 
quantity of items ordered and for the frequency of use or replacement (if applicable). The information should 
include the enrollees diagnosis and other pertinent information including, but not limited to, duration of the 
enrollees condition, clinical course (worsening or improvement), prognosis, nature and extent of functional 
limitations, other therapeutic interventions and results, past experience with related items, etc." 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an addition to lower limb prosthesis have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an addition to lower limb prosthesis, vacuum pump, residual limb 
volume management and moisture evacuation system (L5781).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computer-assisted musculoskeletal surgical 
navigational orthopedic procedure (0055T). 
 
You asked the Plan to pre-approve a computer-assisted musculoskeletal surgical navigational orthopedic 
procedure. 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 a computer-assisted musculoskeletal surgical navigational orthopedic procedure. Our reviewer says that the requested items/services are not 
considered medically reasonable and necessary in this case. Our physician reviewer found provided medical 
records document significant symptomatic knee osteoarthritis with failure of non-surgical treatments, but 
records do not address the medical necessity, safety or efficacy of the computer-assisted component to the 
partial knee replacement surgery. Records do not show that the computer-assisted component to the partial 
knee replacement surgery is reasonable and necessary for the diagnosis or treatment of illness or injury or to 
improve the functioning of a malformed body member. 
 
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 computer-assisted musculoskeletal surgical navigational orthopedic procedure 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a computer-assisted 
musculoskeletal surgical navigational orthopedic procedure (0055T).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a privacy flap, back (K0108).  
 
You asked the Plan to pre-approve a privacy flap. You say that the services are necessary. The Plan denied 
your request. The Plan says the requested item is not primarily medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a privacy flap, back (K0108).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an unspecified preventive procedure (D1999) provided on 
April 21, 2023. 
 
You asked the Plan to pay for the dental service. You say that you were not properly informed that the services 
were not authorized. The Plan denied your request. The Plan says the denial of payment for this service is 
correct, because the unspecified preventive procedure is not covered by the Plan. 
 
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, the requested item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an 
unspecified preventive procedure (D1999) provided on April 21, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 home health skilled nursing visits.  

You asked the Plan to pre-approve home health services. You say that you would like to request 
reconsideration of the denied home health skilled nursing visits and that the services requested are medically 
necessary. The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the clinical 
documentation does not specify any acute clinical concern, medication or plan of care changes. The records do 
not show that 8 additional home health skilled nursing visits are required to effectively provide treatment, care, 
and/or services in order to improve the enrollee's condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 8 home health skilled nursing visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve  an electronic connection (E2311), harness (E2313), and 
expandable controller (E2377). 
 
You asked the Plan to pre-approve the items. You say that  when three or more power seating 
functions/actuators/motors are provided, one unit of E2311, one unit of E2377, and one unit of E2313 are 
allowed. The Plan denied your request. The Plan says although there are three requested power options (tilt, 
recline and elevating leg rests), there is not a medical need to control these power options through the joystick. 
 
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 items. Our physician reviewer 
found the enrollee has sufficient strength and function in upper extremities to manage standard power drives. 
 
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 items have not been met. Therefore, we decided that the Plan does not have 
to pre-approve  an electronic connection (E2311), harness (E2313), and expandable controller (E2377).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral radiographic image (D0230) and the core 
buildup (D2950) for tooth #12 provided on March 15, 2023, and March 27, 2023. 
  
You asked the Plan to pay for the dental services. You say that the provider is now an in-network provider, and 
the dental services should be covered as in-network. The Plan denied your request. The Plan says your benefit 
for the intraoral radiographic image has already been exhausted. Also, the core buildup is not covered by the 
Plan. 
 
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 the Plan paid for an intraoral radiographic image (D0220) on March 15, 2023; therefore, your benefit for 
the intraoral radiographic image (D0230) was exhausted on the date of service of March 15, 2023. The core 
buildup is not covered under the Plan's dental benefit. Therefore, we decided that the Plan does not have to pay 
for the intraoral radiographic image (D0230) and the core buildup (D2950) for tooth #12 provided on March 
15, 2023, and March 27, 2023.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the screening study for abdominal aortic aneurysm (76706)
provided on January 24, 2023.

You asked the Plan to pay for the screening study for abdominal aortic aneurysm. You say that the services at
issue were a necessity for your care. The Plan denied your request. The Plan says that your benefit for the
requested item or service has already been exhausted. Maximus overturned the Plan's denial because of a lack
of information. The Plan requested a reopening and stated that this benefit has been exhausted. The Plan is
correct in this case. The Plan has provided your Explanation of Benefits indicating they covered an abdominal
aortic aneurysm screening for you on February 10, 2022. Your contract with the Plan clearly says that an
abdominal aortic aneurysm screening is covered one time. This means that the Plan correctly covered one
abdominal aortic aneurysm screening and that there is no coverage for a second test. Therefore, we decided that
the Plan does not have to pay for the screening study for abdominal aortic aneurysm (76706) provided on
January 24, 2023.