Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hearing aids (V5261) provided August 8, 2020. 
 
You asked the Plan to pre-approve the hearing aids. You say that the hearing aids were medically necessary. 
The Plan denied your request. The Plan says hearing aids obtained from non-contract providers are not a 
covered item. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for 
hearing aids only when obtained from the plan contracted provider.  
 
We looked at the file and the Plan's rules. The hearing aids were not purchased from the plan's contracted 
supplier. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not 
been met. Therefore, we decided that the Plan does not have to pre-approve hearing aids (V5261) provided 
August 8, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan does not have to provide coverage for a continuous glucose monitor (CGM) for the enrollee.
You asked the Plan to provide coverage for a CGM. You say that this device is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the Plans denial stating this equipment would be beneficial. The Plan requested a reopen and stated that the argument was not whether or not it was beneficial but the fact that the required Medicare criteria were not met.
Our Medical Director looked at the case file and the reopen request. Our Medical Director says that at issue is coverage for a continuous glucose monitor. The Maximus Physician Reviewer determined that the enrollee has met the required criteria. The Plan requested a reopen and stated that the medical records indicate that the enrollee is on Levemir Flex pen once a day, with no adjustments mentioned. The Plan states that the request did not meet the criteria set forth in the LCD. The plan is correct in this case. The medical records in the case file indicate that the enrollee is on 36 units of Levemir once a day. The documentation does not support that the enrollee is insulin-treated with multiple (three or more) daily injections of insulin or a Medicare-covered continuous subcutaneous insulin infusion (CSII) pump. The coverage criteria established by the LCD were not met in this case based on the available documentation. 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 CGM have not been met. Therefore, we decided that the Plan does not have to provide coverage for a continuous glucose monitor (CGM) for the enrollee.
Appeal type: ER
Decision: Favorable

We decided that the Plan does not have to waive the cost share charged for emergency room services and observation services provided to the enrollee from April 17, 2020 to April 19, 2020.
You asked the Plan to waive this cost share. You say that you do not believe this cost share is correct. The Plan denied your request. The Plan says this cost share was charged based on the services provided and the Plan contract agreement. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct contract language.
The Plan is correct in this case. 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 cost share for both emergency room services and outpatient hospital or observation services. The Plan has provided documentation to show you were not admitted to the hospital as an inpatient. This means the cost share for emergency room services and observation services apply. 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 cost share charged for emergency room services and observation services provided to the enrollee from April 17, 2020 to April 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the services. You say that this denial is unfair. The Plan denied your 
request. The Plan says services that are not medically necessary are 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 the services. Our reviewer says that the 
requested monitor is not considered medically reasonable and necessary in this case. Our physician reviewer 
found based on the notes provided, the monitor would not be considered therapeutic as there was no failure of 
glucometer use. You are not using insulin multiple times a day or requiring frequent testing to assist frequent 
medication adjustments. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a continuous glucose monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0667) for the 
enrollee. 
 
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 failed four-week trial of conservative therapy. 
 
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 the documentation does not reveal evidence of true lymphedema of the chest, trunk, or abdomen on an 
objective physical examination. The enrollee does not have unique characteristics that would indicate the 
segmented pump over a standard pump and there is no evidence of a complete four-week trial of a standard 
pump. 
 
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 (E0652, E0667) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CardioMEMS HF System and implantation (33289, 
C2624). 
 
You asked the Plan to pre-approve CardioMEMS HF System. You say that the enrollee needs this device. The 
Plan denied your request. The Plan says it is not covered under the current Medicare Category B 
Investigational Device Exemption Requirements. 
 
The Plan must follow Medicare rules. CMS posts Medicare-covered Category A or B IDE studies on their 
website. Providers participating in and seeking Medicare reimbursement for items and services in Category A 
or B IDE studies, prior to submitting claims, are responsible for checking the CMS Coverage Website to 
identify whether CMS has approved the study for purposes of Medicare coverage. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the CardioMems device have not been met. Specifically, this hospital is not participating in the 
study. The member would have to be enrolled in the study, and they are not. Therefore, we decided that the 
Plan does not have to pre-approve CardioMEMS HF System and implantation (33289, C2624).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary. 
 
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 the documentation does not support that the enrollee in this case requires services at 
the LTACH that are not available at the acute care hospital where she is currently receiving care. The requested 
LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of 
the enrollee 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 LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for exercise equipment purchased on August 31, 
2020. 
 
You asked the Plan to reimburse you for the equipment. You say that this should be paid for. The Plan denied 
your request. The Plan says the equipment was purchased prior to October 1, 2020. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers exercise 
equipment in lieu of a gym membership starting 10/1/20. 
 
The Plan's rules for coverage of gym benefits/exercise equipment have not been met because the equipment 
was purchased prior to 10/1/20. Therefore, we decided that the Plan does not have to reimburse you for 
exercise equipment purchased on August 31, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periapical x-rays, bitewing x-rays, and fillings rendered 
on August 24, 2020. 
 
You asked the Plan to pay for these services. You say that the staff informed you that the dentist had a contract 
with the Plan. The Plan denied your request. The Plan says the services are not covered. 
 
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. The Plan covers one periapical 
x-ray per calendar year, one bitewing x-ray per calendar year, and two fillings per calendar year. 
 
The file shows that you received periapical x-rays and bitewing x-rays on August 24, 2020. You previously 
received these services on January 2, 2020 that the Plan covered. These services are only covered once per 
calendar year. The services on August 24, 2020 exceeded the benefit limit. 
 
The file shows that you received three fillings on August 24, 2020. The Plan covered two of these fillings, per 
the supplemental benefit. The third filling exceeds the benefit limit of two procedures per calendar year. 
 
The file shows that you received an unspecified preventive dental procedure billed with code D1999 on August 
24, 2020. These services are not listed as covered by your supplemental benefit. 
 
Therefore, we decided that the Plan does not have to pay for the periapical x-rays, bitewing x-rays, and fillings 
rendered on August 24, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric services. 
 
You asked the Plan to pre-approve these services. You say that you have extreme panic attacks and anxiety 
disorder. The Plan denied your request. The Plan says the services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records show that you were 
admitted to the hospital on February 12, 2021 with depression and inability to function. It is not expected that 
you would improve in a reasonable period of time, as you are not showing dangerousness to yourself or others 
and have no auditory or visual hallucinations. You are not showing any behavioral issues. You are cooperative 
and compliant with care. It does not appear that the services are necessary to improve your condition or for the 
purpose of diagnosis. The inpatient services are not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve inpatient psychiatric services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the 
enrollee. 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says there is no daily skilled nurse or therapist need. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above 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 the admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee has stabilized medically and 
is ready for discharge from the hospital. The enrollee does not require skilled nursing and/or skilled therapy 
services on a daily basis. She is medically stable and can receive further rehab services at a lower level of care. 
Although further rehab services would be appropriate to improve function, as a practical matter, the 
intermittent skilled services can be provided at a lower level of care than a skilled nursing facility. The enrollee 
does not have any parental medication; complex wound care or nutrition given via a feeding tube. She is 
medically stable without any acute exacerbations of chronic medical problems. Her physical function is at or 
near her baseline and she can receive services at a lower level of care. Admission to a SNF for inpatient skilled 
rehab services 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 admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided from February 18, 2020 to 
February 22, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the laboratory services provided from 
February 18, 2020 to February 22, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you were previously independent, and you need the 
therapy to get back to your previous lifestyle. The Plan denied your request. The Plan says your medical 
conditions are stable and you do not need complex wound care. You do not need a multidisciplinary team or 
visits from a physician. You are unable to do three hours a day of therapy and your care can be handled in a 
less intensive setting. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 that the complexity of your nursing, medical and rehabilitation needs does not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  
 
You were admitted for right below the knee amputation. Your medical conditions are stable. There are no 
medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. You do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record documents a need for physical and 
occupational therapy, it does not document a need for an intensive rehabilitation program. 
 
There is not a reasonable expectation that this patient 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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the out of network cost share for periodic oral evaluation 
(D0120), prophylaxis (D1110), the crown (D2752), core build up (D2950), and the endodontic therapy 
(D3330) provided from July 21, 2020, to September 3, 2020. 
 
You asked the Plan to waive the out of network cost share for the dental services. You say that when you 
enrolled in this plan, you asked if your dentist was in network. You say that you were advised that your dentist 
was in network. You also say that you signed up for this plan as a result. The Plan denied your request. The 
Plan says the provider in this case is out of network. The Plan says that the provider was paid based on the 
Maximum Allowable Charge (MAC). The Plan also says that out of network providers can bill you for the 
difference between what was billed and what was paid. 
 
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, dental services that you receive out of 
network have a higher cost share amount. Additionally, the Evidence of Coverage clearly states that out of 
network providers can bill you for the difference between what was billed and what was paid. Therefore, we 
decided that the Plan does not have to waive the out of network cost share for periodic oral evaluation (D0120), 
prophylaxis (D1110), the crown (D2752), core build up (D2950), and the endodontic therapy (D3330) provided 
from July 21, 2020, to September 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an addition, endoskeletal system, above knee, flexible 
protective outer surface covering system for the enrollee. 
 
You asked the Plan to pre-approve the protective outer surface covering system. You say that this is medically 
necessary. The Plan denied your request. The Plan says that there is no documentation that supports that the 
member's activity subjects him to harsh environmental situations or that he engages in any extraordinary 
activities that would justify the need for extra protection with a flexible outer surface covering system. 
 
The Plan must follow Medicare rules. Medicare rules say that the protective outer surface covering system is 
used by a beneficiary who has special needs for protection against unusually harsh environmental situations.  
 
We looked at the file and Medicare rules. The record does not show the enrollee is subject to harsh 
environmental situation. Based on this information, we decided that Medicare rules for coverage of the 
protective outer surface covering system have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an addition, endoskeletal system, above knee, flexible protective outer surface covering system 
for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 9, 2020, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were rendered by an out-of-network provider without prior authorization. 
 
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 the medical services provided on September 9, 
2020, by an out-of-network (OON) provider.