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

 
We decided that the Plan has to pre-approve admission to a long-term acute care hospital (LTACH) for the 
enrollee. 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says that this is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The plan has not substantiated their denial. The plan has not provided any 
medical records for review to MAXIMUS, even though it is clear they had them available. Therefore, we 
decided that the Plan has to pre-approve admission to a long-term acute care hospital (LTACH) for the 
enrollee. 
  
 
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: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) and computed tomography 
(CT) of the lumbar spine. 
 
You asked the Plan to pre-approve the MRI and CT scan. You say that there is concern regarding the x-rays the 
enrollee received in June, that there is a possible delayed union. You say that the requested imaging studies are 
needed urgently, as the enrollee may require repeat operative intervention. The Plan denied your request. The 
Plan says that the information provided does not show what has been done to help the enrollee, nor does it 
explain how these tests will change how the doctor treats the enrollee. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs and 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 MRI and CT scan. Our reviewer 
says that the requested MRI and CT scan are medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee presents with persistent low back pain with right lower extremity radiculopathy. 
She reports severe symptoms, including weakness and limited standing and walking endurance. She is status 
post multiple lumbar spine surgeries, including osteotomy at the L4 level and revision anterior lumbar 
interbody fusion at L4 with instrumentation from L3 to the sacrum on November 20, 2019. X-rays on June 14, 
2020 showed possible delayed union. The provider indicates that CT scan is warranted to ensure solid bone 
consolidation across the interbody at L4 and L5, as well as an MRI to evaluate nerve compression and possible 
right-sided foraminal involvement. This enrollee has risk factors for non-union, including continued smoking. 
Imaging has been requested to determine if additional operative intervention is indicated. Evidence based 
medical guidelines would support the requested diagnostic studies to assist in treatment planning. 
 
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 MRI and CT scan have been met. Therefore, we decided that the Plan has to 
pre-approve magnetic resonance imaging (MRI) and computed tomography (CT) of the lumbar 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: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Ilumya (J3245). 
 
You asked the Plan to pre-approve Ilumya. You say that this is medically necessary. The Plan denied your 
request. The Plan says that step therapy requirements have not been 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 Ilumya. Our reviewer says that the 
criteria for coverage of Ilumya have been met. Our physician reviewer found while the enrollee has not tried 
Stelara and either Remicade or Inflectra as required by the Plan's step therapy rules, the required drugs are less 
efficient and safe compared to Ilumya. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Ilumya have been met. Therefore, we decided that the Plan has to pre-approve 
Ilumya (J3245).  
 
 
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency ambulance service and ground mileage 
(A0428, A0425) provided on February 14, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the non-emergency ambulance service and ground mileage. You say that the 
services provided were medically necessary. 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 non-emergency ambulance service and ground 
mileage (A0428, A0425) provided on February 14, 2020, by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued admission to an inpatient mental health 
facility. 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says there are no new or acute symptoms that require 24 hour inpatient care. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 admission. Our reviewer says that 
the requested services are not medically reasonable or necessary. Our physician reviewer found you could be 
treated in a lesser restrictive setting, as you were not showing any suicidal or homicidal ideation, auditory or 
visual hallucinations. You were not showing any behaviors or aggression being cooperative and compliant 
while not showing any acute threats to safety. 
 
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 admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued admission to an inpatient mental health facility.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental extractions (D7210 x2) provided on March 23, 2020. 
 
You asked the Plan to pay for dental extractions. You say that you are appealing for reconsideration of the 
denied charges. The Plan denied your request. The Plan says the services are not a covered benefit under the 
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. This service is not listed in your EOC as a covered benefit; therefore, it 
is not covered. Therefore, we decided that the Plan does not have to pay for dental extractions (D7210 x2) 
provided on March 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the gingival flap procedure (D4240) and gingival 
irrigation (D4921). 
 
You asked the Plan to pre-approve the gingival flap procedure (D4240) and gingival irrigation (D4921). You 
say that you want to appeal the denial. The Plan denied your request. The Plan says the services are not covered 
benefits. 
 
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 
gingival flap procedure (D4240) and gingival irrigation (D4921).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the wheeled folding walker purchased on May 20, 
2020. 
 
You asked the Plan to reimburse you for the wheeled folding walker. You say that you purchased the rollator 
from this supplier because it was a great price. The Plan denied your request. The Plan says you obtained 
durable medical equipment from a provider who does not participate with Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items provided directly by a provider who is not eligible to take Medicare payment.   
 
Payment cannot be made for items purchased from this provider because this provider is not a medical provider 
and is not enrolled in Medicare. Durable medical equipment purchased privately through the internet, or by 
private purchase are not eligible for coverage by your Medicare governed health plan. Therefore, we decided 
that the Plan does not have to reimburse you for the wheeled folding walker purchased on May 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the established patient assisted living visit (99336) provided 
on May 27, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the established patient assisted living visit. You say that you would like this 
claim reprocessed and approved for payment. 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 established patient assisted living visit (99336) 
provided on May 27, 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 group 3 power wheelchair and accessories. 
 
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied 
your request. The Plan says this has been deemed not appropriate or medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient?s condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 wheelchair. Our reviewer says that 
the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found the 
documentation is not clear that you are not able to perform ADLs with the current wheelchair. The 
documentation does not reveal why your mobility deficit is unable to be helped by the current wheelchair, 
which is an M300 HD per documentation and able to have seat width and depth adjusted for conditions such as 
 
 
weight change. The documentation is conflicting on your function. A 9/21/20 physician progress note indicates 
that you have has normal strength and tone, therefore it is not clear why you cannot perform MRADLs or use 
an assistive device. The documentation does not support that the requested group 3 power wheelchair will 
significantly improve MRADL performance in the home over her current wheelchair. 
 
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 wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a group 3 power wheelchair and accessories.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for comprehensive medical examination and 
evaluation (92014) eye refraction services (92015) scanning computerized ophthalmic diagnostic imaging 
(92134) visual field test (92083) provided June 29, 2020. 
 
You asked the Plan to waive the copayment for the vision services. You say that you had a routine eye exam 
and you thought that there was no copay for a routine eye exam. The Plan denied your request. The Plan says 
the claim processed and the correct copayment was applied per the plan benefits. 
 
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 $35 
copay per visit for Medicare covered exams to diagnose and treat diseases of the eye.  
 
You have been asked to pay $35 copay for the vision services. The vision services fall within the Vision care 
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 comprehensive medical 
examination and evaluation (92014) eye refraction services (92015) scanning computerized ophthalmic 
diagnostic imaging (92134) visual field test (92083) provided June 29, 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. The Plan denied your request. The Plan says the 
enrollee is lacking a second comorbid condition requiring active management. 
 
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 physician 
reviewer found that the enrollee was brought to the hospital by the EMS after he desaturated on his baseline 
vent setting. He was also fund to have a blood pressure of 91/48 with tachycardia. The enrollee still requires 
acute hospital level of care services, and is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where he is 
currently receiving care. There are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The requested LTACH services are not 
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be 
furnished safely and effectively only on an inpatient basis. 
 
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Interspinous Spacer (22870, 22869). 
 
You asked the Plan to pre-approve a Vertiflex Interspinous Spacer. You say that the services are necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria has not been met. 
 
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 a Vertiflex Interspinous Spacer. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the device is experimental. More research is needed to show safety and 
efficacy. 
 
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 Vertiflex Interspinous Spacer have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a Vertiflex Interspinous Spacer (22870, 22869).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection of aminophyllin, provided on January 31, 2020. 
 
You asked the Plan to pay for the injection, aminophyllin, up to 250 mg (J0280). You say that the Plan should 
pay this claim. The Plan denied your request. The Plan says the documentation submitted did not include 
documentation that aminophyllin was administered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code J0280 is injection, aminophyllin, up to 250 mg.  
 
We find that CPT code J0280 is not supported in the medical record. Specifically, the medical records do not 
show that this drug was administered. Based on this information, we decided that Medicare rules for coverage 
of the injection, aminophyllin, up to 250 mg (J0280) have not been met. Therefore, we decided that the Plan 
does not have to pay for the injection of aminophyllin, provided on January 31, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance provided on June 4, 2019 and 
October 28, 2019. 
 
You asked the Plan to pay for periodontal maintenance. You say that this was a regular cleaning not a 
periodontal cleaning. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the periodontal maintenance billed is 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
periodontal maintenance provided on June 4, 2019 and October 28, 2019.
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 enrollee suffered a hip fracture and needs rehab. 
The Plan denied your request. The Plan says the enrollee does not require an intensive, multidisciplinary team 
approach to therapy, or close physician monitoring. 
 
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 physician reviewer found 
that the enrollee is at a moderate assist level for sitting up, minimal assist for standing, and minimal assist for 
taking steps using a rolling walker. The enrollee does not require the intensity of services provided at an IRF.  
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation. 
 
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 inpatient rehabilitation facility (IRF) admission and services.