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

We decided that the Plan does not have to pre-approve Metaxalone. 
 
You asked the Plan to pre-approve Metaxalone. You say that the medication is necessary. The Plan denied your 
request. The Plan says you do not have a Medicare Part D benefit or a separate pharmacy benefit managed by 
the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
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 Metaxalone.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a SleepOvation mattress. 
 
You asked the Plan to pre-approve a SleepOvation mattress. You say that this is medically necessary for you. 
The Plan denied your request. The Plan says that the requested mattress does not meet the Medicare coverage 
criteria. 
 
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 SleepOvation mattress.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99212) provided on July 15, 2020. 
 
You asked the Plan to pay for an office visit. You say that this was billed correctly. The Plan denied your 
request. The Plan says this was not billed with a correct diagnosis code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Some 
ICD-10-CM codes indicate laterality, specifying whether the condition occurs on the left, right or is bilateral. 
 
We find that the billing of this claim is not supported in the record. Specifically, this claim was billed with 
diagnosis codes I87.331 and I87.332, indicating right and left laterality. There is a more appropriate bilateral 
code for this diagnosis. Based on this information, we decided that Medicare rules for coverage of an office 
visit have not been met. Therefore, we decided that the Plan does not have to pay for an office visit (99212) 
provided on July 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the retreatment of a previous root canal (D3348) provided on 
October 7, 2020. 
 
You asked the Plan to pay for the dental service. You say that the original root canal was done 36 years ago. 
You say that the root was infected along with the gums. You say that the root canal was done to treat an 
infection and not to redo the original root canal. You say that you would like to have coverage awarded as a 
new infection, which it was. The Plan denied your request. The Plan says the retreatment of a previous root 
canal is not listed as a covered service. The Plan also says that any services not listed 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. The Evidence of Coverage clearly states that any services not listed are 
not covered. Therefore, we decided that the Plan does not have to pay for the retreatment of a previous root 
canal (D3348) provided on October 7, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation (90791) provided 
March 21, 2019. 
 
You asked the Plan to pay for the psychiatric evaluation. You say that you did not receive proper notice of this 
enrollee's benefit determination, hence, the untimely submission of the claim. The Plan denied your request. 
The Plan says the provider submitted this claim after the timely filing limitations. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the psychiatric evaluation was not filed until September 8, 2020. This means 
that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the psychiatric diagnostic evaluation (90791) provided March 21, 
2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve neurosurgery consultation visit. You say that many respectable providers do 
not accept this Plan, and you are sick of being sick. The Plan denied your request. The Plan says the denial of 
authorization for this service is correct, because this provider is out-of-network with the Plan and you can be 
treated by an in-network specialist. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the medical services to be provided by an out of network (OON) provider.  
 
Your complaints regarding your experiences with this Plan are considered to be grievances. MAXIMUS 
Federal Services does not have the jurisdiction to address grievances. Please contact the Plan for more 
information about your grievances.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that the requested 
transportation is necessary. The Plan denied your request. The Plan says the requested additional transportation 
trips exceed the benefit limit. Therefore, coverage criteria has not been met. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan?s coverage rules apply in this 
case. The Plan covers a maximum of 12 one-way transportation trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller (E2377), harness (E2313), 
electronic connection (E2311) and a one piece malleable calf panel (A9900) for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan 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.  
 
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 requested items/services are not considered medically reasonable and necessary in this case. The 
Miscellaneous DME supply (A9900), accessory is not medically necessary as this is for a calf rest/pad 
replacement and a replacement item at this time exceeds the patient's medical need. The documentation does 
not reveal that the patient requires other types of proportional input devices or non-proportional input devices. 
The patient does not need to operate 3 or more powered seating actuators through the drive control, a separate 
display, other electronic devices, or an attendant control. The patient's strength and function are sufficient for 
the patient to control any power options through their own individual switches. Our physician reviewer found 
that the enrollee's condition does not meet criteria for coverage of these services. 
 
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 an expandable controller (E2377), harness (E2313), electronic connection (E2311) and a 
one piece malleable calf panel (A9900) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Colestid. 
 
You asked the Plan to pre-approve Colestid. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
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 Colestid.  
 
Benefits for Colestid 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lung cancer screening with low dose computed 
tomography (LDCT). 
 
You asked the Plan to pre-approve a lung cancer screening with LDCT. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that lung cancer screening with LDCT is covered when 
specific criteria is 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 lung cancer screening with LDCT. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found you have no 
smoking history which is a CMS requirement for LDCT. While it is true significant radon and/or asbestos 
exposure predispose a patient to an increased risk of lung cancer, there is no quantification as to the exposure 
of same to establish medical necessity for CT of the chest let alone low dose lung CT. 
 
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 lung cancer screening with LDCT have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a lung cancer screening with low dose computed tomography 
(LDCT).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hyalgan. 
 
You asked the Plan to pre-approve the Hyalgan. You say that you would like reconsideration because this drug 
is medically necessary. The Plan denied your request. The Plan says the member does not meet step therapy 
exception criteria 
 
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 the Hyalgan. Our reviewer says that the 
enrollee has not trialed viscosupplemental treatments such as Orthovisc and Monovisc.  Step therapy, as 
outlined by the plan, requires these be trialed first. Our physician reviewer found the documentation does not 
outline contraindications or reasons these medications were not considered or that the plan?s required drugs 
would likely be less effective and/or likely have adverse effects for the enrollee. 
 
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 Hyalgan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Hyalgan.
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 these services are medically necessary. The Plan 
denied your request. The Plan says that you can safely receive the services you need in other settings. 
 
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. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You were admitted for chest pain. 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 you will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition 
does not meet Medicare criteria for IRF care. 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care beyond 
January 15, 2021. 
 
You asked the Plan to pre-approve the continued SNF care. You say that the enrollee is not able to be sent 
home at this time as she would be unable to care for herself. The Plan denied your request. The Plan says the 
enrollee has progressed to the point where daily skilled care is not needed. 
 
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 continued SNF care. Our reviewer 
says that daily skilled services are not necessary. Our physician reviewer found the beneficiary is a female with 
a right tibia fracture. From a nursing perspective, the beneficiary received oral medications. The beneficiary 
had stable vital signs. She was treated for pain with effect. Regarding rehabilitation services, the beneficiary 
received PT and OT in the SNF. By the dates in question, the beneficiary was at a minimal to moderate assist 
level with transfers and bed mobility and she used a wheelchair for mobility. The beneficiary required varying 
assist with ADLs. She remained at a toe-touch weightbearing status. 
 
There are no identifiable skilled therapy service needs. There are no identifiable skilled nursing service needs. 
This beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in a 
skilled nursing facility 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 the continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care beyond January 15, 2021.
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 there is no documentation provided necessitating admission to a LTACH. The 
enrollee still requires acute hospital level of care services. The enrollee does not require services at the LTACH 
that are not available at the acute care hospital where they are currently receiving care. There are no services 
available at the LTACH that the enrollee requires that are not available at the health care setting being offered 
by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for 
the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient 
basis. 
 
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: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Botox. 
 
You asked the Plan to pre-approve Botox. The Plan denied your request. The Plan says that the enrollee does 
not have a diagnosis that is indicated for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Botox. Our physician reviewer found 
that the enrollee has epiphora after eye lid surgery. The use is supported by one of the major drug compendia. 
Micromedex states that an injection of botulinum toxin type A into the palpebral lobe of the lacrimal gland may 
improve symptoms of functional epiphora. Therefore, Botox is safe and effective, and otherwise reasonable and 
necessary for this enrollee's epiphora. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox have been met. Therefore, we decided that the Plan has to pre-approve 
Botox.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Myrbetriq 50mg tab for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that the enrollee has been stable on this medication. The 
Plan denied your request. The Plan says this is a benefit exclusion. 
 
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 a Myrbetriq 50mg tab for 
the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an EEG provided on June 19, 2020 by an out of network 
(OON) provider. 
 
You asked the Plan to pay for an EEG. You say that you would like this claim reprocessed and paid. The Plan 
denied your request. The Plan says prior authorization was not obtained. The Plan says that the referring 
provider is out-of-network. The Plan says that the member's primary care physician did not refer these services. 
 
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 an EEG provided on June 19, 2020 by an out of 
network (OON) provider.