Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. 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 IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for altered mental status and falls. Medical conditions are stable. There are no medical needs requiring 
inpatient admission. There are no complex nursing or rehabilitation needs. The patient does not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the medical record documents a need for physical and occupational 
therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable 
expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF. 
 
 
 
 
 
 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the core buildup (D2950). 
 
You asked the Plan to pre-approve the core buildup. You say that the services requested are necessary to treat 
the enrollee's condition. The Plan denied your request. The Plan says the requested service 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 the 
core buildup (D2950).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve these services. You say that the services are the only thing that helps. 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 chronic left knee pain. The requested genicular nerve RFA is considered experimental/investigational in 
nature and is the subject of ongoing clinical trials. The services 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 genicular nerve radiofrequency ablation (RFA).  
 
Local Coverage Determination (LCD) L34993 referenced by the Plan does not provide coverage criteria for the 
services at issue and was not used in the MAXIMUS determination.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve whole body bone/joint imaging services. 
 
You asked the Plan to pre-approve the whole-body bone/joint imaging services. You say that the requested 
imaging is medically necessary in order to check the process of care. The appellant says that scans are done 
every 3 months. The appellant says that the type of cancer he has, has made its way to the bone. The Plan 
denied your request. The Plan says you are in a clinical trial and Original Medicare covers the routine costs. 
 
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 whole body bone/joint imaging services 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 whole body bone/joint imaging services.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the cervical spine. 
 
You asked the Plan to pre-approve these services. You say that your only relief is pain medication and you do 
not want to have physical therapy. The Plan denied your request. The Plan says that 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 abnormal plain film of the neck spine and radicular pain. The MRI is indicated and is reasonable and 
medically necessary, given the abnormal plain x-rays and radicular nature of your pain. 
 
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 been met. Therefore, we decided that the Plan has to pre-
approve magnetic resonance imaging (MRI) of the cervical spine.  
 
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: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that there is no clinical advantage of LTACH over the current 
acute hospital setting. 
 
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. The patient 
appears to be improving but requires additional short term acute care services only, based on the records, which 
can safely be completed at the current facility. The patient does not require services at the LTACH that are not 
already available at the current facility. Our physician reviewer found that the enrollee's condition does not 
meet Medicare criteria for LTACH 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 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 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on May 21, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the hospital bed accessory (E0315). You say that the claim should be paid. The 
Plan denied your request. The Plan says the supplier where you got this is not a Medicare Certified provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says to receive payment for covered Medicare items or services from either Medicare (in the case of an 
assigned claim) or a Medicare beneficiary (in the case of an unassigned claim), a provider or supplier must be 
enrolled in the Medicare program. 
 
The requested provider in this case is not enrolled in the Medicare program. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the medical services provided on May 21, 2020 by 
an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Fluzone high-dose quad for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this must be used for a medical issue that is approved by the FDA. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the services. The 
Plan follows the same rules.  
 
The FDA has not approved this specific vaccine for use in people under the age of 65. Therefore, we decided 
that the Plan does not have to pre-approve Fluzone high-dose quad for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services. 
 
You asked the Plan to pay for the ambulance services. You say that you fell so the ambulance staff picked you 
up off the floor and checked you, but you had no physical damage so they left. 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 June 11, 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitoring (CGM) system. 
 
You asked the Plan to pre-approve a CGM system. You say that the item is 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 CGM devices are 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 CGM system. Our reviewer says that 
the item is not medically necessary. Our physician reviewer found the enrollee is not taking multiple insulin 
 
 
shots per day nor are they checking their blood glucose 4 times per day. Hence, the enrollee does not meet the 
coverage criteria. It is also not noted why a traditional glucometer would not suffice and why the enrollee needs 
a CGM. This does not mean that the enrollee would not benefit from a CGM but it does mean that they do not 
meet the provided criteria for CGM coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a CGM system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a continuous glucose monitoring (CGM) system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve biological materials to aid in tissue regeneration 
(D4265) for teeth # 7 and 10, and the bone replacement graft for ridge preservation (D7953) for teeth # 7 and 
10. 
 
You asked the Plan to pre-approve the dental services. You say that the bone in your mouth has deteriorated. 
You say that you need implants put in because the situation has caused sores in your mouth. You also say that 
you have to numb your tissue before you eat or drink. The Plan denied your request. The Plan says biological 
materials to aid in tissue regeneration is not listed as a covered service. The Plan also says that bone 
replacement graft for ridge preservation is not listed as a covered 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. 
 
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 
biological materials to aid in tissue regeneration (D4265) for teeth # 7 and 10, and the bone replacement graft 
for ridge preservation (D7953) for teeth # 7 and 10.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pulmonary perfusion imaging. 
 
You asked the Plan to pre-approve pulmonary perfusion imaging. You say that you are appealing. The Plan 
denied your request. The Plan says the denial of authorization for this service is correct, because this test is 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 pulmonary perfusion imaging. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found it would be difficult, if not impossible, to interpret the perfusion portion of 
this study without the matching ventilation portion. This enrollee has chronic obstructive pulmonary disease 
(COPD), which affects both perfusion and ventilation and can vary with time. Thus it will be impossible to 
attribute any changes in perfusion to thromboembolic disease. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of pulmonary perfusion imaging have not been met. Therefore, we decided that the 
Plan does not have to pre-approve pulmonary perfusion imaging.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc-One. 
 
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 right knee 
osteoarthritis. She has not tried and failed the Plan's required drugs of Orthovisc and Monovisc. The records do 
not show that the required drugs would be contraindicated or less effective; therefore, the Synvisc-One 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 Synvisc-One.
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 routine transportation. You say that you need additional trips for testing and 
scheduled surgery. The Plan denied your request. The Plan says the denial of authorization for additional 
routine transportation is correct, because routine transportation beyond 24 one-way trips per year is not covered 
by the Plan. 
 
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 24 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on February 13, 2020, by an 
OON provider. 
 
You asked the Plan to pay for diabetes self-management training. You say that you were advised that you did 
not need a referral since you are diabetic. The Plan denied your request. The Plan says rules for payment have 
not been met. 
 
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 has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the medical services provided on February 13, 
2020, by an OON provider.  
 
Your complaint about receiving erroneous or misleading information from a representative of the provider is 
not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by 
the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ECG provided on July 24, 2020. 
 
You asked the Plan to waive the copayment for an ECG. You say that you disagree with the charges because 
the ECG was part of an annual wellness exam. The Plan denied your request. The Plan says the claims were 
processed correctly and you are being charged the correct 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 a $75 
copayment for diagnostic procedures and tests. 
 
You received an ECG on July 24, 2020. An ECG is not included in an annual wellness exam. Therefore, you 
are responsible to pay the allowed amount of $17.30, which is less than the $75 copayment.   
 
You have been asked to pay $17.30 for an ECG. An ECG falls within the outpatient diagnostic tests and 
therapeutic services and supplies 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 
an ECG provided on July 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says the services are not covered. 
 
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).