Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 14 day/sensor/flash monitoring 
system. 
 
You asked the Plan to pre-approve a Freestyle Libre 14 day/sensor/flash monitoring 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 therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 a Freestyle Libre 14 day/sensor/flash 
monitoring system. Our reviewer says that the item is not medically necessary. Our physician reviewer found 
information was not provided to show that you are taking multiple insulin shots per day;  hence you do not 
meet 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 Freestyle Libre 14 day/sensor/flash monitoring system have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 14 day/sensor/flash 
monitoring system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a neurostimulator for the enrollee. 
 
You asked the Plan to pre-approve the stimulator. You say that this is medically necessary. The Plan denied 
your request. The Plan says there is no indication of an evaluation by an orthopedic spine surgeon. 
 
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 stimulator. Our reviewer says that 
the requested stimulator is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee does not have an evidence-based indication for a SCS trial. There has been no 
surgical evaluation. The request is deemed 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 the stimulator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a neurostimulator for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex surgery (22869, 22870). 
 
You asked the Plan to pre-approve the Vertiflex surgery. You say that this is medically necessary. The Plan 
denied your request. The Plan says this surgery 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 the Vertiflex surgery. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and 
efficacy of the device. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Vertiflex surgery have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex surgery (22869, 22870).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional mileage for routine transportation trips. 
 
You asked the Plan to pre-approve additional mileage for routine transportation trips. You say that the 
additional mileage is needed. The Plan denied your request. The Plan says the requested additional mileage 
exceeds the benefit limit. Therefore, coverage criteria has not been met. 
 
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 12 one-way transportation trips per calendar year when each one-way trip does not 
exceed 50 miles per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve additional mileage for routine transportation trips.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the visit to the emergency room (99220) 
provided on September 14, 2020. 
 
You asked the Plan to waive the copayment for the emergency room visit. You say that you paid $883 out of 
pocket at the time of the service, and then were billed a second time after the service. The Plan denied your 
request. The Plan says they paid their amount for emergency care to the hospital, and that reimbursement of 
any money you paid to the hospital beyond the agreed-upon copayment is the responsibility of the hospital. 
 
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 $120 
copayment for emergency care.  
 
You have been asked to pay a $120 copayment for the emergency room visit. An emergency room visit falls 
within the emergency care benefit category. This means that the Plan has asked you 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 visit to 
the emergency room (99220) provided on September 14, 2020.  
 
Your complaint about having paid for this service previously and requiring reimbursement for money paid 
directly to the hospital is not a valid appeal for medical coverage. We read your letter and understand that you 
may like to potentially request reimbursement or file a grievance against the hospital. Medicare does not permit 
us to make a decision about these types of complaints. You may call 1-800-MEDICARE (1-800-633-4227) for 
help or more information about what you can do in this case. TTY users should call 1-877-486-2048.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that these are medically necessary. The Plan denied 
your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the removal of extra bone in the roof of the mouth 
(D7473). 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says this service 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 service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the removal 
of extra bone in the roof of the mouth (D7473).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a custom breast prosthesis (L8035). 
 
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 is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that if an L8035 breast prosthesis is billed, it will be 
denied as not reasonable and necessary. 
 
The requested prosthesis is not considered reasonable and necessary by Medicare. Based on this information, 
we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a custom breast prosthesis (L8035).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gloves. 
 
You asked the Plan to pre-approve the gloves. You say that you are paralyzed and must do digital stimulation 
to take the fecal matter out. The Plan denied your request. The Plan says the health plan and Medicare do not 
cover non-reusable disposable supplies for home use, such as bandages, gauze, tape, antiseptics or dressings. 
 
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 gloves.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341 x 4), core 
build ups, including any pins when required (D2950 x 2), and porcelain crowns (D2750 x 2). 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says these services are not payable as supplemental 
dental services must be received from a participating provider in order to be 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.  
 
We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these services have not been met. Specifically, the contract states that supplemental dental services 
must be received from a participating provider in order to be covered by the Plan. You are requesting 
authorization of these services to be provided to the enrollee; however, you are not a participating provider 
with the Plan. Therefore, we decided that the Plan does not have to pre-approve periodontal scaling and root 
planing (D4341 x 4), core build ups, including any pins when required (D2950 x 2), and porcelain crowns (D2750 x 2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a first 15 minutes of deep sedation/general anesthesia 
(D9222) and each subsequent 15 minute increment of deep sedation/general anesthesia (D9223). 
 
You asked the Plan to pre-approve the deep sedation/general anesthesia. You say that you feel that deep 
sedation is necessary for the procedure. The Plan denied your request. The Plan says these services are not 
covered by your 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, 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 a 
first 15 minutes of deep sedation/general anesthesia (D9222) and each subsequent 15 minute increment of deep 
sedation/general anesthesia (D9223).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CT scan of the lumbar spine for the enrollee. 
 
You asked the Plan to pre-approve the scan. You say that this is needed for complaints of back pain. The Plan 
denied your request. The Plan says there is no information showing why another scan is needed. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the scan. Our reviewer says that the 
requested scan is not medically reasonable or necessary. Our physician reviewer found a review of the records 
shows no rationale for repeating the CT of the lumbar spine. Rather the clinical notes from 12/17/20 indicate a 
desire for MRI of the lumbar spine and PT.  This approach is very reasonable for a patient with post 
laminectomy syndrome. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve CT scan of the lumbar spine for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical procedure for the isolation of a tooth with a 
rubber dam (D3910) for tooth # 5. 
 
You asked the Plan to pre-approve the dental service. You say that you do not want to return to this provider 
because of their billing tactic to divide procedures. You also say that this service is part of the surgical 
procedure. The Plan denied your request. The Plan says surgical procedure for the isolation of a tooth with a 
rubber dam is not listed as a covered service. The Plan also says that any services that are not listed are not 
covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, 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 a 
surgical procedure for the isolation of a tooth with a rubber dam (D3910) for tooth # 5.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a retainer crown (D6752) and pontic (D6242). 
 
You asked the Plan to pre-approve a retainer crown and pontic. You say that you believe these are covered 
services. 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 pre-approve a 
retainer crown (D6752) and pontic (D6242).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve the SNF services. You say that the clinical information provided supports 
that SNF care is medically necessary. The Plan denied your request. The Plan says the enrollee does not require 
daily skilled nursing services or skilled rehabilitation services. 
 
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 the SNF services. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have 
documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee 
is ambulating more than 100 feet and tending to ADLs with minimal supervision. Daily skilled services are not 
required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The 
enrollee's care needs at this point are custodial and, as a practical matter, can be provided at a lower level of 
care. 
 
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 services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve homemaker services. 
 
You asked the Plan to pre-approve the homemaker services. You say that you broke your arm recently. You 
say that you need assistance with cooking. You say that you need to get food delivered as you cannot drive. 
You also say that you do not have relatives that can help you. The Plan denied your request. The Plan says 
homemaker services which include basic household assistance such as light housekeeping or light meal 
preparation is not covered under any condition. 
 
The Plan must follow Medicare rules. Medicare rules say that custodial care is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the homemaker services have not been met. Therefore, we decided that the Plan does not have to 
pre-approve homemaker services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an upper partial denture. 
 
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 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 an 
upper partial denture.
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 this equipment must be provided by an in-network 
provider. 
 
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for acute inpatient rehabilitation facility (IRF) admission and 
services. 
 
You asked the Plan to pay for IRF care. You say that IRF care is medically necessary. The Plan denied your 
request. The Plan says rules for IRF care have not been met. 
 
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 pay for 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. There are no 
medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. In addition, 
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. Finally, 
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 pay for acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Favorable

We decided that the Plan does not have to waive the $837.50 ($167.50 copayment x 5 days) cost share charged for skilled nursing facility (SNF) services provided from November 1, 2019, to November 6, 2019.
You asked the Plan to waive this cost share. You say that you do not believe this copayment is correct. The Plan denied your request. The Plan says this copayment was charged based on the services provided and the Plan contract agreement. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan states that you also received inpatient SNF services from August 23. 2019, to September 12, 2019 and again from October 17, 2019 to October 31. 2019. The Plan states because there was no 60-day period where you were without inpatient skilled nursing services, the SNF stay from November 1, 2019, to November 6, 2019 requires a copayment.
The Plan is correct in this case. 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 $167.50 per day for days 21 to 100 of a SNF stay. This third stay was within a 60-day benefit period and therefor the copayment was applied correctly. 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 $837.50 ($167.50 copayment x 5 days) cost share charged for skilled nursing facility (SNF) services provided from November 1, 2019, to November 6, 2019.