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

We decided that the Plan does not have to pre-approve Xiidra. 
 
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 self-administered drugs are not covered. 
 
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 Xiidra.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Qutenza. 
 
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 self-administered drugs are not covered. 
 
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 Qutenza.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing. 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee has 5-6 millimeter pocket 
depths. The Plan denied your request.  
 
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 the dental 
services when the services are medically necessary and reasonable.  
 
The file shows that periodontal scaling and root planing for four or more teeth per quadrant were requested. We 
asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the dental services. Our physician 
reviewer found that there are no teeth remaining on the upper arch. Therefore, the request for periodontics in 
the upper right and upper left quadrants are not medically necessary. On the lower arch, teeth #22-28 remain.  
There are 3 teeth on the lower left quadrant, and 4 on the lower right. The lower right quadrant, from the 
available view, does not show any appreciable bone loss. Without a loss of attachment, there would be no 
medical necessity for the requested procedure. The lower left quadrant appears to have some loss of bone. 
However, the number of involved teeth are less than the four required under the submitted code. There is no 
necessity for the requested procedure for the requested quadrants.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve periodontal scaling and root planing.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Procrit. 
 
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 step therapy requirement is not met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a history of chronic 
kidney disease and anemia. She has not tried and failed the Plan's required drug, Retacrit. The records do not 
show that the required drug would be contraindicated or less effective; therefore, the Procrit is 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 Procrit.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan does not have to waive the copayment charged for an office visit provided on September 8, 2020.
You asked the Plan to waive this copayment. You say that this was an annual wellness visit and should be no charge. The Plan denied your request. The Plan says your physician billed for services that stemmed beyond a wellness visit. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional medical records to show this was billed as an office visit by the provider and not as an annual wellness visit.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare states limited services are covered under the annual wellness visit. The Plan has provided records to show there were services billed that are not typically included in the annual wellness visit. Therefore, we decided that the Plan does not have to waive the copayment charged for an office visit provided on September 8, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan does not have to pay for inpatient admission for knee surgery for the enrollee.
You asked the Plan to pay for inpatient admission after knee replacement surgery. You say that inpatient admission is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct inpatient criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for an inpatient admission for a total knee replacement. The Maximus Physician Reviewer determined that, based on the enrollee's past medical history and underlying health conditions, inpatient admission was reasonable. The health plan has requested a re-opening, citing an error on the face of the evidence. The Plan requested a reopen and stated the enrollee's "medical history, signs or symptoms, and current medical state do not show medical complexities warranting an in-patient stay as evidenced by the documentation provided." The medical records provided show the enrollee is a 71-year-old woman whose general health is described as good, with no pertinent past medical history. Our Medical Director says that the plan is correct in this case. The medical records do not support that it was reasonable to expect that the enrollee's necessary hospital care would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient admission have not been met. Therefore, we decided that the Plan does not have to pay for inpatient admission for knee surgery for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair. 
 
You asked the Plan to pre-approve a power wheelchair. You say that your driveway causes the motor and 
power supplies to go bad. The Plan denied your request. The Plan says the records do not show that your 
current wheelchair cannot be repaired. 
 
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 a power wheelchair, which serves the same purpose as the requested wheelchair. 
The documentation provided does not indicate the current wheelchair has irreparable damage. Based on this 
information, we decided that the Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a power wheelchair.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the lumbar epidural steroid injection services. We decided that the 
Plan does not have to pre-approve .  
 
You asked the Plan to pre-approve the lumbar epidural steroid injection services. You say that the records 
provided support the need for the requested injection services. The Plan says that there are no notes saying that 
the enrollee has already had physical therapy or explanation as to why anesthesia is needed. The Plan says that 
the enrollee does not meet the requirements for coverage of the requested injection services. 
 
We decided that the Plan has to pre-approve the lumbar epidural steroid injection services.  
 
The Plan must follow Medicare rules. Medicare rules say that epidural steroid injections are covered for certain 
medical indications.   
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve lumbar epidural steroid injection 
services. Our physician reviewer says that the criteria for coverage of lumbar epidural steroid injection services 
have been met. Our physician reviewer found that the enrollee has chronic low back pain and has been taking 
Aleve for pain. The enrollee had physical therapy in the past but did not find it beneficial. An MRI shows 
multi-level degenerative disc disease, facet arthropathy, and spinal stenosis. Our physician reviewer found that 
the lumbar epidural steroid injection services are medically necessary. Therefore, we decided that the Plan has 
to pre-approve the lumbar epidural steroid injection services.  
 
We also decided that the Plan does not have to pre-approve monitored anesthesia care. 
 
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 monitored anesthesia care. Our 
physician reviewer says that the criteria for coverage of the monitored anesthesia care have not been met. Our 
physician reviewer found that the enrollee does not have any unstable medical issues documented. There is no 
indication that monitored anesthesia care is medically necessary. Therefore, we decided that the Plan does not 
have to pre-approve . 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that you need this because it is extremely difficult 
and hazardous for you to shower without one. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an intermittent limb compression device (E0676). 
 
You asked the Plan to pre-approve an intermittent limb compression device. 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 a PCD 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 an intermittent limb compression 
device. Our reviewer says that the item is not medically necessary. Our physician reviewer found there is no 
evidence that the requested device is medically necessary and reasonable to diagnose, treat or otherwise 
manage your health. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an intermittent limb compression device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an intermittent limb compression device (E0676).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hospital outpatient clinic provided on May 4, 2020. 
 
You asked the Plan to pay for the hospital outpatient clinic. The Plan denied your request. The Plan says that 
the enrollee must receive care from in-network providers with the exception of emergency or urgent care, 
dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network 
provider, which requires prior authorization from the plan. 
 
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 a hospital outpatient clinic provided on May 4, 2020.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pre-approve Intensity-Modulated Radiation Therapy (IMRT). 
 
You asked the Plan to pre-approve IMRT. You say that the services are necessary. The Plan denied your 
request. The Plan says that medical necessity has not been established. Therefore, coverage criteria has not 
been met. 
 
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 IMRT. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found for this enrollee, with a complex treatment field (encompassing internal mammary and 
supraclavicular nodes) the improvement in the IMRT vs. standard plan with respect to lung dose exposure is 
evident in the provided records. IMRT would be furnished in accordance with accepted standards of medical 
practice and other criteria are met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IMRT have been met. Therefore, we decided that the Plan has to pre-approve 
Intensity-Modulated Radiation Therapy (IMRT).  
 
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 a crown (D2751) for tooth #3. 
 
You asked the Plan to pre-approve the crown. You say that tooth #3 has a large restoration that is fractured. 
You also say that a crown is necessary for the tooth's stability and total restoration. The Plan denied your 
request. The Plan says the medical records received did not support the medical necessity for the request. 
 
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 the crown 
when the services are medically necessary and reasonable.  
 
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 crown. Our reviewer says that the 
crown is not medically reasonable and necessary. Our physician reviewer found the enrollee's dental record and 
radiographs do not indicate significant coronal breakdown due to caries or fracture to warrant a crown 
restoration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the crown have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a crown (D2751) for tooth #3.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve durable medical equipment to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve durable medical equipment. You say that you would like approval for these 
services. The Plan denied your request. The Plan says there are in-network providers available for 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 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 
durable medical equipment to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dentures (D5863, D5862, D5865). 
 
You asked the Plan to pre-approve dentures. You say that this should be considered a medical service. The Plan 
denied your request. The Plan says this is 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. Therefore, we decided that the Plan does not have to pre-approve 
dentures (D5863, D5862, D5865).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the face bone graft provided on May 19, 2020. 
 
You asked the Plan to pay for the face bone graft. You say that you were under the impression that this service 
was included in the $4,400.00 that you paid on May 19, 2020. The Plan denied your request. The Plan says this 
service is not a Medicare covered benefit. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for 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 pay for the face bone graft provided on 
May 19, 2020.
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 admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the guidelines for coverage of LTACH care have not 
been met. The Plan says that the enrollee's 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 the enrollee was admitted to the current acute care hospital with small bowel 
resection for perforated viscus complicated by anastomotic leak with repair. He was intubated after respiratory 
arrest requiring trach and PEG placement. Since, he has failed weaning attempts and required TPN but is now 
tolerating tube feeds. The records show that the enrollee is more stable but requires additional short-term acute 
care services for additional weaning attempts which can be safely administered at the current facility. The 
enrollee does not require services at the LTACH that are not already available at the current facility. There are 
no services at the LTACH that the enrollee requires that are not already available and covered at the current 
facility. Therefore, this request for LTACH services will be considered not medically necessary at this time. 
Transfer to a lower level of care may be considered when treatment has completed. 
 
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an implant supported crown, and a custom abutment. 
 
You asked the Plan to pre-approve the dental services. You say that the abutment is needed to put the 
implanted crown into the gum. 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 file shows that an implant supported crown was requested. We looked at the file and the rules. This service 
is only covered once every 84 months. Based on this information, we decided that the Plan's rules for coverage 
have not been met.  
 
The file shows that a custom abutment was requested. Although the Plan offers a dental benefit in excess of 
Medicare coverage, the requested service is not among those covered under this benefit. Therefore, we decided 
that the Plan does not have to pre-approve an implant supported crown, and a custom abutment.