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

We decided that the Plan does not have to pre-approveCapecitabine for the enrollee.You asked the Plan to pre-approveCapecitabine. You say that this drug is medically necessary.The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated Maximus did not apply the correct criteria.Our Medical Director looked at the case file and the reopen request. The enrollee is a 75-year-old woman with a diagnosis of Malignant (primary) neoplasm, unspecified. She has adenocarcinoma of unknown origin which is metastatic to bone and liver. The cancer institute note dated July 8, 2020 documents a plan to proceed with gemcitabine and capecitabine as soon as she receives it as per protocol. The oncologist writes that the enrollee's diagnosis is unknown, but it is possibly gastrointestinal, and needs immediate treatment. The oncologist states that he would like to treat the enrollee as GI with Capecitabine and Gemzar, and that Capecitabine is medically necessary to improve her quality of life. However, the Plan is correct in this case. The requested use of capecitabine in combination with gemcitabine for adenocarcinoma of unknown origin is not FDA-approved. The use is not supported in any of the CMS approved compendia.There were no supporting citations for the requested combination found in a PubMed search.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Capecitabine have not been met.Therefore, we decided that the Plan does not have to pre-approveCapecitabine for the enrollee.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan does not have to pre-approve Prolia for the enrollee.You asked the Plan to pre-approve Prolia. You say that Prolia is medically necessary.The Plan denied your request. The Plan says the Medicare criteria for Prolia were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated Maximus did not apply the correct LCD criteria.Our Medical Director looked at the case file and the reopen request. At issue is coverage for Prolia.The enrollee is a 74-year-old woman with a diagnosis of age-related osteoporosis without current pathological fracture. It is documented that the enrollee is not taking calcium because she had transient hypercalcemia. The enrollee is taking vitamin D. The prescribing physician writes that "the enrollee is getting 3 to 4 servings of dietary calcium regularly and does not have to be on supplemental calcium to be getting enough calcium for Prolia". Therefore, the Plan is correct in this case. The Medicare LCD and LCA A52399: Denosumab (Prolia, Xgeva) states that "Supplemental calcium and vitamin D are required." The original reviewer did not address this requirement. Medicare coverage criteria were not met based on the medical records. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met.Therefore, we decided that the Plan does not have to pre-approve Prolia for the enrollee
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), prophylaxis (D1110), 
and the bitewing x-rays (D0274) provided on June 9, 2020. 
 
You asked the Plan to pay for the dental services. You say that you advised the plan representative that you 
wanted the same plan as the previous year. You say that you were not advised that the plan changed let alone 
was deleted. You also say that had you known that you need to activate the option, you would have. The Plan 
denied your request. The Plan says you were not enrolled in the dental plan on the date of service. 
 
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 periodic oral evaluation 
(D0120), prophylaxis (D1110), and the bitewing x-rays (D0274) provided on June 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CardioMEMS device. 
 
You asked the Plan to pre-approve the requested services. You say that recent data supports the clinical benefit 
of remote hemodynamic monitoring. The Plan denied your request. The Plan says there are not enough studies 
to show the device consistently improves the health of those with the enrollee's condition. 
 
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 requested services. Our physician 
reviewer found that the enrollee has a history of NYHA class III congestive heart failure with preserved 
ejection fraction requiring hospital admission. In this circumstance, therapy change based on data obtained 
from a CardioMEMS device has been demonstrated in only one trial to help reduce hospital readmission 
compared to standard medical therapy. Concerns have been raised about potential bias in this trial calling into 
question the results. The efficacy of the CardioMEMS device is uncertain at this time according to leading 
authorities, and not recommended in current guidelines for the treatment of heart failure.  Therefore, the device 
is still considered experimental/investigational. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS device.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services. 
 
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says you are 
receiving adequate and necessary rehab in the inpatient rehab facility. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF services. Our physician reviewer 
found that from a nursing perspective, you received oral medications, had stable vital signs, and your lungs 
were clear. There are no identifiable skilled nursing service needs. Regarding rehab services, you are at a 
standby assist to supervision level with functional mobility. You require varying assist with activities of daily 
living. Although there are identifiable skilled therapy service needs, you do not require skilled nursing or 
therapy services on daily basis. You do not meet severity of illness or intensity of service criteria for an 
inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a skilled nursing facility (SNF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Pegfilgrastim injection (J2505) received 
on April 24, 2020, and a Fosaprepitant injection (J1543) received on April 22 and May 6, 2020. 
 
You asked the Plan to waive the coinsurance for a Pegfilgrastim injection and a Fosaprepitant injection. You 
say that you are contesting this charge. The Plan denied your request. The Plan says the correct coinsurance 
was applied. 
 
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 20% 
coinsurance for chemotherapy drugs and all other drugs covered under Medicare Part B.  
 
You have been asked to pay $766.28, or 20% of the Plan-allowed amount of $3,831.39, for a Pegfilgrastim 
injection on April 24, 2020. You have also been asked to pay $53.46, or 20% of the Plan-allowed amount of 
$267.30, and $37.53, or 20% of the Plan-allowed amount of $187.65, for a Fosaprepitant injection received on 
April 22 and May 6, 2020, respectively. A Pegfilgrastim injection and a Fosaprepitant injection fall within the 
"Medicare Part B prescription drugs" 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 
Pegfilgrastim injection (J2505) received on April 24, 2020, and a Fosaprepitant injection (J1543) received on 
April 22 and May 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for urgent care center services you received on 
May 2, 2020. 
 
You asked the Plan to waive the copayment for the urgent care center services. You say that you would like to 
appeal this bill. The Plan denied your request. The Plan says you were charged this copayment correctly. 
 
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 $65 
copayment for urgently needed services.  
 
You have been asked to pay a $65 copayment for the urgent care center services. 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 urgent care center services you received on May 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on July 
7, 2020. 
 
You asked the Plan to pay for the comprehensive oral evaluation. You say that this was your first dental visit of 
the year, and it had been about 9 months since your last dental appointment. You also say that you were told 
you could have a dental cleaning and exam once every 6 months. The Plan denied your request. The Plan says 
this service exceeds the frequency limitation in your benefit plan. 
 
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, comprehensive oral evaluation 
(D0150) is limited to one procedure every three plan years. The record shows that you received a 
comprehensive oral evaluation (D0150) on July 30, 2019, and your comprehensive oral evaluation (D0150) 
benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive 
oral evaluation (D0150) provided on July 7, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care from May 5th, 2020, 
through May 8, 2020. 
 
You asked the Plan to pay for the SNF care. You say that you needed SNF care. The Plan denied your request. 
The Plan says rules for SNF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the SNF stay. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee does not meet severity of illness 
or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the SNF stay have not been met. Therefore, we decided that the Plan does not 
have to pay for the skilled nursing facility (SNF) care from May 5th, 2020, through May 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the transitional care management services and new patient 
assisted living visit (99495, 99327) provided on March 9, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the transitional care management services and new patient assisted living visit. 
You say that authorization should not be needed under telemedicine. The Plan denied your request. The Plan 
says prior authorization was not obtained by the facility or the provider; therefore, payment has been correctly 
denied. 
 
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 transitional care management services and new 
patient assisted living visit (99495, 99327) provided on March 9, 2020, by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a porch, deck, and ramps for a bathroom. 
 
You asked the Plan to pre-approve the items. You say that this is needed for an accessible bathroom. The Plan 
denied your request. The Plan says these items are not medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a porch, deck, and ramps for a bathroom.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for diagnostic radiology provided by a 
participating provider on May 7, 2020. 
 
You asked the Plan to waive the copayment for an MRI. You say that you were told by the provider that there 
would be a $0 copayment. The Plan denied your request. The Plan says the correct copayment has been 
applied. 
 
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 $295 
copayment for outpatient diagnostic tests/diagnostic radiology.  
 
You have been asked to pay a $295 copayment for an MRI. An MRI falls within the outpatient diagnostic 
tests/diagnostic radiology 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 diagnostic 
radiology provided by a participating provider on May 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a heavy duty power scooter. 
 
You asked the Plan to pre-approve a heavy duty power scooter. You say that this is medically necessary. The 
Plan denied your request. The Plan says that you do not meet criteria for a heavy duty scooter. 
 
The Plan must follow Medicare rules. Medicare rules say that you must weigh between 285 and 450 pounds for 
a heavy duty power operated vehicle to be covered.  
 
We looked at the file and Medicare rules. The file indicates you do not weigh between 285 and 400 pounds. 
Based on this information, we decided that Medicare rules for coverage of a heavy duty power scooter have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a heavy duty power scooter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a functional electrical stimulation (FES) cycle (E1399). 
 
You asked the Plan to pre-approve a FES cycle. You say that this should be covered because it will benefit the 
patient and is not used for walking. The Plan denied your request. The Plan says this is not covered for the 
enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that coverage for the use of NMES/FES is limited to 
SCI patients for walking, who have completed a training program which consists of at least 32 physical therapy 
sessions with the device over a period of three months.  
 
We looked at the file and Medicare rules. The record does not show that the enrollee has a spinal cord injury or 
that the requested device will be used for walking. Based on this information, we decided that Medicare rules 
for coverage of a FES cycle have not been met. Therefore, we decided that the Plan does not have to pre-
approve a functional electrical stimulation (FES) cycle (E1399).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two endodontic procedures (D3999 x2), two endodontic 
therapies (D3320 x2), and consultation (D9310) provided on April 14, 2020. 
 
You asked the Plan to pay for the endodontic procedures, endodontic therapies, and consultation. You say that 
you were told your insurance would cover these procedures. You also say that you are on financial assistance 
with the Plan. The Plan denied your request. The Plan says unspecified endodontic procedure is not a covered 
benefit. The Plan also says that the cost-sharing responsibilities for the endodontic therapies and consultation 
were pre-disclosed. 
 
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, unspecified endodontic procedure 
(D3999) is not among those covered under this benefit. The contract also clearly states that you are responsible 
for a $395 copayment for endodontic therapy (D3320), and you are responsible for a $70 copayment for a 
consultation (D9310).  
 
The Plan also confirmed that you were informed prior to the procedure that the unspecified endodontic 
procedures would not be covered. Therefore, we decided that the Plan does not have to pay for the two 
endodontic procedures (D3999 x2), two endodontic therapies (D3320 x2), and consultation (D9310) provided 
on April 14, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for radiofrequency ablation, nerves innervating the sacroiliac 
joint, with imaging guidance (fluoroscopic or computed tomography) (64625) provided June 24, 2020. 
 
You asked the Plan to pay for radiofrequency ablation. You say that you are sending proof of the enrollee's 
previous back/hop medical records to dispute as reconsideration for claim CPT 64625 LT denial. The Plan 
denied your request. The Plan says the records provided do not support the service at issue was medically 
necessary for the enrollee's unique clinical scenario. 
 
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 pay for radiofrequency ablation. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found radiofrequency ablation of the lateral sacral branches is considered experimental and 
investigational because of the wide variation in efficacy reported in the peer reviewed literature. Therefore, the 
request is considered not medically reasonable or 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 radiofrequency ablation have not been met. Therefore, we decided that the Plan 
does not have to pay for radiofrequency ablation, nerves innervating the sacroiliac joint, with imaging guidance 
(fluoroscopic or computed tomography) (64625) provided June 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the preventive procedure and pulpal debridement provided 
on June 24, 2020. 
 
You asked the Plan to pay for the preventive procedure and pulpal debridement. You say that you thought that 
this provider would be covered by your insurance. The Plan denied your request. The Plan says these 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. 
 
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 pay for the 
preventive procedure and pulpal debridement provided on June 24, 2020.