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

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the left shoulder. 
 
You asked the Plan to pre-approve these services. You say that you have tingling in your left arm and are 
concerned it may be related to your heart. The Plan denied your request. The Plan says the services are not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the submitted records show that you 
have left shoulder pain. The records indicate that you have full range of motion on exam. No plain films are 
noted in the record. There is no evidence of an abnormal shoulder joint exam and no x-rays have been 
performed. The records do not support that the MRI is reasonable or medically necessary 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve magnetic resonance imaging (MRI) of the left shoulder.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist visit provided. 
 
You asked the Plan to waive the copayment for the specialist visit. You say that you feel you should not be 
responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied 
your request. The Plan says you received services provided by a specialist on the date of service at issue in this 
appeal. The Plan says that the correct copayment has applied per your contract with the Plan. 
 
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 a $30 
copayment for each specialist visit for Medicare-covered benefits. 
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received a specialist visit. 
You have been asked to pay a $30 copayment for the specialist visit. The specialist visit 
falls within the Physician/Practitioner services 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 
copayment for the specialist visit provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve these services. You say that you need to check your blood sugar levels 
seven times per day. The Plan denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a therapeutic CGM is covered when specific 
criteria are 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 these services. Our reviewer says that 
you do not meet the criteria for coverage. Our physician reviewer found the submitted records show that you do 
not take multiple doses of insulin daily on a sliding scale that is adjusted by your blood sugar readings. You do 
not meet the criteria for coverage of a therapeutic CGM; therefore, the services are 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the spinal cord stimulator. 
 
You asked the Plan to pre-approve the spinal cord stimulator. You say that you would like reconsideration 
because this service is medically necessary. The Plan denied your request. The Plan says the records do not 
show that the member has demonstrated pain relief with a temporarily implanted electrode or that you have a 
covered diagnosis. 
 
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 spinal cord stimulator. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the member does not have an evidence based indication for a spinal cord stimulator 
trial. 
 
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 spinal cord stimulator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the spinal cord stimulator.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sacroiliac (SI) joint nerve block injections. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
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 services are not medically necessary. Our physician reviewer found the submitted records show that you 
have low back pain and had SI joint fusion surgery on April 4, 2017. The pain radiates to both of your legs. 
There is no evidence in the submitted records of a clinical picture suggestive of an SI joint injury or disease. 
There are not at least three positive exam findings of SI joint issues on physical exam. The SI nerve blocks are 
therefore 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 sacroiliac (SI) joint nerve block injections.  
 
Local Coverage Determination (LCD) L35457 referenced by the Plan does not include coverage criteria for the 
SI joint and was not used in the MAXIMUS determination.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve impacted tooth removal. 
 
You asked the Plan to pre-approve the dental services. You say that this is medically necessary to help you eat. 
The Plan denied your request. The Plan says this is not a covered benefit. 
 
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 
(D7241) are not among those covered under this benefit. D7241 is not listed as a covered code in your dental 
contract. Therefore, we decided that the Plan does not have to pre-approve impacted tooth removal.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on November 9, 2018. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was 
submitted after the timely filing limit. 
 
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 services was not filed until August 3, 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 services provided on November 9, 2018.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve bilateral sacroilliac joint injections. 
 
You asked the Plan to pre-approve the injections. You say that you would like reconsideration because this 
service is medically necessary. The Plan denied your request. The Plan says that this service is not considered 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 injections. Our reviewer says that 
the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the members sacroilliac joint diagnostic testing is positive and the member is continuing home 
exercises. The member had had oral medication trials. 
 
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 injections have been met. Therefore, we decided that the Plan has to pre-
approve bilateral sacroilliac joint injections.  
 
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: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for post-stabilization inpatient care received at an out of network hospital 
on June 24 to June 25, 2020. 
 
You asked the Plan to pay for post-stabilization inpatient care. You say that the Plan did not respond timely to 
the hospital's transfer request. The Plan denied your request. The Plan says that rules for payment have not 
been met. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required. Pre-approval is not required when the Plan does not respond to a request for pre-approval 
within one hour or cannot be reached. 
 
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 pay for post-stabilization inpatient care. Our 
reviewer says that the Plan's denial is unwarranted. Our physician reviewer found that the hospital complied 
and informed the Plan along the way of the status of the enrollee. Due to the lag time in action by the Plan, the 
enrollee was admitted. The Plan should be responsible for the charges. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of post-stabilization inpatient care have been met. Therefore, we decided that the 
Plan has to pay for post-stabilization inpatient care received at an out of network hospital on June 24 to June 
25, 2020.  
 
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

 
We decided that the Plan does not have to pre-approve an interim lower partial denture (D5821). 
 
You asked the Plan to pre-approve this item. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says this item is not a covered benefit under your dental policy. 
 
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 is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an interim lower 
partial denture (D5821).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Magnetic resonance imaging (MRI), breast. 
 
You asked the Plan to pre-approve a breast MRI. You say that having a mammogram causes you considerable 
discomfort and pain. The Plan denied your request. The Plan says the clinical information provided does not 
meet criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a breast MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve 
Magnetic resonance imaging (MRI), breast.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an extra transmitter. 
 
You asked the Plan to pre-approve an extra transmitter. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested item is a duplicate. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have an order and approval for a continuous glucose monitor and supplies, which 
includes a transmitter. The transmitter on the order serves the same purpose as an extra transmitter. In addition, 
only one (1) unit of service of code K0553 may be billed to the DME MACs at a time. Therefore, we decided 
that the Plan does not have to pre-approve an extra transmitter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve therapeutic parenteral drugs and collection of 
microorganisms for culture and sensitivity. 
 
You asked the Plan to pre-approve the dental services. You say that you are in severe pain and suffering. The 
Plan denied your request. The Plan says this is not a covered benefit. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement 
of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or 
paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve therapeutic parenteral 
drugs and collection of microorganisms for culture and sensitivity.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided to the enrollee from April 29, 
2020, to May 27, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the claim submitted does not have a valid treatment authorization code billed on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the claim submitted cannot be paid 
as billed due to the omission of a required code. Based on this information, we decided that Medicare rules for 
coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for home 
health services provided to the enrollee from April 29, 2020, to May 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive oral evaluation - new or established patient 
(D0150) provided on July 28, 2020. 
 
You asked the Plan to pay for comprehensive oral exam. You say that the service was medically necessary. The 
Plan denied your request. The Plan says you have exhausted your plan benefits for this service. 
 
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 
comprehensive exam every three years. 
 
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. Specifically, records indicated you received a comprehensive oral 
exam on April 23, 2019, that the Plan covered. This means you have exhausted your benefit frequency 
limitation and the service is not covered. Therefore, we decided that the Plan does not have to pay for 
comprehensive oral evaluation - new or established patient (D0150) provided on July 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture (D5211) and mandibular 
partial denture (D5212). 
 
You asked the Plan to pre-approve the maxillary partial denture and mandibular partial denture. You say that 
your current dentures are not comfortable, and have never fit correctly. The Plan denied your request. The Plan 
says these services are allowed one time every sixty months. The Plan also says that you had these services less 
than sixty months ago. 
 
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, maxillary dentures are limited to one 
of codes D5110, D5130, D5211, D5213 once per sixty months, and mandibular dentures are limited to one of 
codes D5120, D5140, D5212, or D5214 once per sixty months. The record shows that you received a maxillary 
partial denture (D5213) and a mandibular partial denture (D5214) on December 17, 2019, and your maxillary 
and mandibular denture benefits have been exhausted. Therefore, we decided that the Plan does not have to 
pre-approve a maxillary partial denture (D5211) and mandibular partial denture (D5212).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on February 26, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was 
submitted after the timely filing limit. 
 
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 services was not filed until September 17, 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 services provided on February 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lead wires provided on September 16, 2020. 
 
You asked the Plan to pay for the lead wires. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the items rendered are non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that replacement of lead wires more often than every 
12 months would rarely be reasonable and necessary. 
 
We looked at the file and Medicare rules. Review of the file shows that you provided TENS unit lead wires on 
September 16, 2020. TENS unit lead wires are only covered once every 12 months. The enrollee had already 
received TENS unit lead wires in the last 12 months. Based on this information, we decided that Medicare rules 
for coverage of the lead wires have not been met. Therefore, we decided that the Plan does not have to pay for 
the lead wires provided on September 16, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) 
for the enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says care can be provided in the current inpatient hospital. 
 
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 long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in 
general, LTACHs do not provide clinical services that are materially different than those of short term acute 
care hospitals. The enrollee is receiving acute hospital care, and acute care services have not been denied. 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 admission to a long term acute care hospital (LTACH) for the enrollee.