Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

You asked the Plan to pre-approve Insertion of interlaminar/interspinous process stabilization/distraction 
device, without open decompression or fusion, including image guidance when performed, lumbar; single level 
(22869) and Insertion of interlaminar/interspinous process stabilization/distraction device, without open 
decompression or fusion, including image guidance when performed, lumbar; second level (22870). You say 
that this procedure is minimally invasive and a safer alternative to a laminectomy or spinal fusion. The Plan 
denied your request. The Plan says a review of the current medical literature indicates that this service is 
considered experimental and investigational. 
 
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 Insertion of interlaminar/interspinous 
process stabilization/distraction device, without open decompression or fusion, including image guidance when 
performed, lumbar; single level (22869) and Insertion of interlaminar/interspinous process 
stabilization/distraction device, without open decompression or fusion, including image guidance when 
performed, lumbar; second level (22870). Our reviewer says that the requested items/services are not 
considered medically reasonable and necessary in this case. Our physician reviewer found the interspinous 
spacer device remains experimental. More research is needed to show safety and efficacy of the device. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Insertion of interlaminar/interspinous process stabilization/distraction device, 
without open decompression or fusion, including image guidance when performed, lumbar; single level 
(22869) and Insertion of interlaminar/interspinous process stabilization/distraction device, without open 
decompression or fusion, including image guidance when performed, lumbar; second level (22870) have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a posterior interspinous 
decompression spacer procedure.
Appeal type: Imaging
Decision: Unfavorable

You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says there was no clinical information provided to support medical necessity. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 scan. Our reviewer says that the 
requested scan is not medically reasonable or necessary. Our physician reviewer found in this, there is very 
limited medical information provided for review. Only a prescription was included. In the absence of any 
recent medical records, it cannot be independently determined that the provision of a CT scan for this enrollee 
would be reasonable and necessary. Furthermore, it cannot otherwise be concluded that the use of a CT scan 
would be a more appropriate imaging modality than others (which may provide more diagnostic yield). 
 
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 scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve CT scan of the brain for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

You asked the Plan to pre-approve the kidney transplant evaluation. You say that the enrollee has been residing 
with family for the last year to help with medical care and plan to be caregivers after the transplant. You say 
that the enrollee would greatly benefit from having a transplant in your region. The Plan denied your request. 
The Plan says that in-network providers are available. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis, and 
pre-approved care.   
 
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 kidney transplant evaluation. Our 
reviewer says that the enrollee needs an evaluation as soon as possible to get on the transplant list. Our 
physician reviewer found that dual or multiple listing for a kidney transplant is a service that is encouraged by 
all transplant centers to reduce the amount of time on dialysis. Our reviewer says that this is a medically 
appropriate listing given the enrollee has a caregiver in the area. 
 
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 kidney transplant evaluation have been met. Therefore, we decided that the 
Plan has to pre-approve the kidney transplant evaluation by an out-of-network provider.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient physician services provided on May 8, 2020. 
 
You asked the Plan to pay for the outpatient physician 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 payable. 
 
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 outpatient physician services 
provided on May 8, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantation of spinal neurostimulator electrodes. 
 
You asked the Plan to pre-approve laminectomy for implantation of neurostimulator electrodes, plate/paddle, 
epidural (63655). You say that the enrollee needs the neurostimulator for chronic pain. The Plan denied your 
request. The Plan says there is no documentation of a screening or trial. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Criteria of a screening and a trial have not been met. Based on this 
information, we decided that Medicare rules for coverage of laminectomy for implantation of neurostimulator 
electrodes, plate/paddle, epidural (63655) have not been met. Therefore, we decided that the Plan does not have 
to pre-approve implantation of spinal neurostimulator electrodes.
Appeal type: Drugs
Decision: Unfavorable

You asked the Plan to pre-approve Novoseven RT. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested drug is not medically necessary. 
 
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 Novoseven RT. Our reviewer says that 
the documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found the enrollee has Glanzmann's thrombasthenia. Novoseven RT is indicated for the treatment of 
bleeding episodes and the prevention of bleeding episodes prior to surgical procedures. In this case, the 
requested drug is not being prescribed for actual usage but rather to have available for self-administration 
should the need arise. The prescription of this drug in this fashion is not supported by the Medicare compendia. 
The record does not indicate that the enrollee has in-dwelling intravenous access. Therefore, the enrollee does 
not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Novoseven RT have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Novoseven RT.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sleep study for the enrollee. 
 
You asked the Plan to pre-approve the study. You say that this is medically necessary. The Plan denied your 
request. The Plan says the current CPAP machine is broken, and the last sleep study was more than ten years 
ago. 
 
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 study. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee has obstructive sleep apnea, and has been treated successfully with CPAP for 15 years. The 
device now requires replacement. A new sleep study is not medically necessary for the enrollee, as she has 
continued to do well on the current CPAP settings. Medicare does not require a repeat sleep study in this 
situation. The CPAP should be replaced and 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 study have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a sleep study for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam radiation therapy (PBRT) for prostate 
cancer. 
 
You asked the Plan to pre-approve the PBRT. You say that the enrollee's health is in danger without this 
treatment being approved by the Plan. The Plan denied your request. The Plan says this treatment is being 
provided in a clinical trial. Routine costs of clinical trials are covered by Original Medicare and not the health 
plan. 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve the PBRT as part of a clinical trial. The Plan does not cover 
routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-
approve proton beam radiation therapy (PBRT) for prostate cancer.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve anterior segment aqueous drainage device, without 
extraocular reservoir, internal approach, into the trabecular meshwork, each additional device insertion 
(0376T). 
 
You asked the Plan to pre-approve the additional insertion device. You say that the enrollee is scheduled for a 
surgical procedure that is medically necessary. The enrollee has glaucoma and has two different dates 
scheduled for the surgery. The Plan denied your request. The Plan says additional device insertion for treatment 
of glaucoma is not a covered benefit because Medicare approves only one device insertion per eye. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the additional insertion device have not been met. Therefore, we decided that the Plan does not 
have to pre-approve anterior segment aqueous drainage device, without extraocular reservoir, internal 
approach, into the trabecular meshwork, each additional device insertion (0376T).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the LTACH services are medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 patient appears to still be unstable and requires additional short-term acute care 
services to further find an effective treatment plan and further stabilize the patient which can be safely done at 
the current facility. The patient does not require services at the LTACH that are not already available at the 
current facility. 
 
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 long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

You asked the Plan to pay for the initial nursing facility care. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require 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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for initial nursing facility care provided on September 8, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the pacemaker surgery provided on 
October 9, 2020. 
 
You asked the Plan to waive the coinsurance for the pacemaker surgery. You say that you believe this balance 
is excessive. You say you live on a fixed income and cannot afford this bill. The Plan denied your request. The 
Plan says you have been asked to pay the correct cost-sharing amount. 
 
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 10% 
coinsurance for Medicare-covered surgery or other services at an in-network outpatient hospital or ambulatory 
surgical center, including but not limited to hospital or other facility charges and physician or surgical charges.  
 
You have been asked to pay $1,132.15 which is less than the standard 10% of the allowed amount for the 
pacemaker surgery. The allowed amount is $12,014.86. The record shows you met your $1,700 maximum out-
of-pocket amount. The pacemaker surgery falls within the "Outpatient Surgery and Other Medical Services at 
Hospital Outpatient Facilities and Ambulatory Surgical Centers" 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 pacemaker surgery provided on October 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) segmental 
pneumatic appliance for use with pneumatic compressor (E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device and appliance. You say that in 
consideration of this member's unique clinical condition you ask the plan to reverse the dial to allow for 
coverage of the prescribed Flexitouch. The Plan denied your request. The Plan says the enrollee does not meet 
the LCD criteria for an advanced lymphedema pump as there is no failed four-week trial of a basic pneumatic 
compression device of either E0650 or E0651. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) segmental pneumatic appliance for use with pneumatic compressor (E0667).
Appeal type: Transportation
Decision: Unfavorable

You asked the Plan to pay for the ambulance services. You say that you were treated in place by the medics. 
The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on September 21, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on September 21, 
2020.
Appeal type: DME/ Orthotics
Decision: Favorable

You asked the Plan to pre-approve the CGM. You say that you feel that you clearly meet all criteria and that 
this CGM should be covered for you. Using a standard blood glucose meter is not an option due to pain and 
easy bruising, and the CGM has helped. You now are on insulin after every meal with the dose adjusted based 
on pre-meal test results, along with the long acting insulin you take daily. The Plan denied your request. The 
Plan says that your fill history of insulin does not support that you are using three daily injections at this time. 
As such, this cannot be covered. 
 
The Plan must follow Medicare rules. Medicare rules say that Plans must forward sufficient information to the 
IRE to support their denials. The rules also say that CGMs may be covered for enrollees who test blood sugar 
four or more times per day, use three or more daily insulin injections, and who adjust the dose of those 
injections based on readings from their tests. 
 
In this case, the medical records support that the enrollee is prescribed one long-acting insulin injection per 
day, as well as an injection with each of the three daily meals. Dose is to be adjusted based on meal readings. 
Although the Plan indicates that the insulin injections have not been filled often enough to support this number 
of injections, not enough specific information was provided to prove this. Specific details regarding the dates of 
when insulin was received, and the amount provided on those dates were requested but no response was 
received by Maximus. Without this information, it cannot be clearly determined that there is non-compliance 
with the prescribed regimen. Based solely on the information in the file, we find that the criteria for CGM 
coverage have been met. Therefore, we decided that the Plan has to pre-approve a therapeutic continuous 
glucose monitor (CGM).  
 
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: Supplemental Benefit
Decision: Unfavorable

You asked the Plan to pre-approve the dental service. You say that you have something wrong with your right 
pallet. You say that you would like to have a biopsy done and possibly surgery for removal. You also say that 
your doctor seemed really concerned due to your diabetes. The Plan denied your request. The Plan says 
incisional biopsy of oral tissue 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, incisional biopsy of oral tissue is 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 pre-approve the incisional biopsy of oral 
tissue (D7286).
Appeal type: DME/ Orthotics
Decision: Unfavorable

You asked the Plan to pay for the supply allowance for therapeutic continuous glucose monitor (CGM). You 
say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the 
documentation is missing required information. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order for the supplies provided in this case.  The record shows 
that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we 
decided that the Plan does not have to pay for the supply allowance for therapeutic continuous glucose monitor 
(CGM) provided on July 9, 2020.