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

 
We decided that the Plan does not have to pre-approve a Group 2 power wheelchair. 
 
You asked the Plan to pre-approve power wheelchair. You say that you need a wheelchair because you fall and 
cannot walk far. The Plan denied your request. The Plan says the denial of authorization for this item is correct, 
because the documentation does not show that a power operated vehicle has been ruled out as an option for 
you. 
 
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 power wheelchair. Our reviewer says 
that you do not meet the Medicare criteria for the requested power wheelchair. Our physician reviewer found 
there is no documentation that the requested power wheelchair would be used to participate in one or more 
mobility-related activities of daily living such as toileting, feeding, dressing, grooming, and bathing in 
customary locations in the home. The records indicate that this power wheelchair would be used for leisure 
activities and community access. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of power wheelchair have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Group 2 power wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a commode chair (E0163). 
 
You asked the Plan to pre-approve the commode chair. You say that you would like reconsideration because 
you are not able to make it to the bathroom with a commode if you are too far away from that bathroom. The 
Plan denied your request. The Plan says there is no documentation that you cannot get to the bathroom. 
 
The Plan must follow Medicare rules. The rules say that a commode chair is covered only for enrollees who are 
confined to a bed or room. 
 
The file does not show that you are confined to a bed or room as defined by Medicare rules. Therefore, we 
decided that the Plan does not have to pre-approve a commode chair (E0163).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a captain's chair (K0108) and red base color (K0108). 
 
You asked the Plan to pre-approve a captain's chair and red base color. You say that these items should be 
covered. The Plan denied your request. The Plan says these items are not necessary. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose and not serve the same purpose as other equipment already available to an enrollee.   
 
The requested red base coat in this appeal does not serve a purpose that is primarily medical in nature. The 
requested captain?s chair is considered duplicative as a captain?s chair is included in the approved power 
wheelchair. Therefore, we decided that the Plan does not have to pre-approve a captain's chair (K0108) and red 
base color (K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Over-bed table (E0274). 
 
You asked the Plan to pre-approve an Over-bed table. You say that you suffer from vertigo due to a tumor in 
your head. There are times you cannot hold your own plate and your daughter has to hold it. You would like to 
make it easier on your daughter. The Plan denied your request. The Plan says this item is a convenience item 
and is not used to treat a medical condition. 
 
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 an Over-bed table (E0274).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the requested physician's services. 
 
You asked the Plan to pre-approve the physician's services. You say that the neurosurgeon took care of your 
back and found the issues that you are having in your hip and is the first physician to diagnose you correctly. 
The Plan denied your request. The Plan says an out- of-network provider may be needed if the Plan does not 
have a doctor who can perform the services that are needed to treat your problem. This service can be safely 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the 
requested physician's services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Mirena intrauterine contraceptive system (J7298). 
 
You asked the Plan to pre-approve a Mirena intrauterine contraceptive system. You say that this is medically 
necessary hormone therapy for the your symptoms. The Plan denied your request. The Plan says coverage of 
this medication is the responsibility of the your Part D prescription drug benefit. The Plan has indicated that 
this request has been sent for a Part D review. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve a Mirena intrauterine contraceptive system (J7298).  
 
Benefits for a Mirena intrauterine contraceptive system may be available under Medicare Part D. Contact the 
Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence garments. 
 
You asked the Plan to pre-approve the supplies. You say that the enrollee needs to wear these 24/7. The Plan 
denied your request. The Plan says this is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence garments.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transit system for a manual wheelchair. 
 
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. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue is a transit system for a manual wheelchair. The function of this item is so that the wheelchair 
can be used outside of the home. Therefore, we decided that the Plan does not have to pre-approve a transit 
system for a manual wheelchair.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve the surgical removal of residual roots for tooth #2. 
 
You asked the Plan to pre-approve the surgical removal of residual roots for tooth #2. You say that the enrollee 
presents with a fractured tooth with remaining tooth roots. You say that the tooth will require removal of each 
root individually after sectioning the tooth and removing the bone. The Plan denied your request. The Plan says 
that the documentation submitted does not support the code requested. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. The Plan covers the surgical 
removal of residual roots for tooth #2 when the services are medically necessary and reasonable. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the surgical removal of residual roots 
for tooth #2. Our physician reviewer found that the coronal structure of tooth #2 is missing, there is no 
adequate structure to grab with forceps or to allow for elevation and bone removal would be expected to be 
necessary in this case to remove the roots. Our physician reviewer found that the Guide to Extractions indicates 
that a tooth that has lost the clinical crown and has only the roots remaining that requires cutting of bone to 
achieve the removal is properly addressed by code D7250. Our reviewer says that the presentation of the tooth 
in the x-ray provided meets the qualifications and as such is reasonable and medically necessary.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the surgical removal of residual roots for tooth #2 have been met. Therefore, we 
decided that the Plan has to pre-approve the surgical removal of residual roots for tooth #2.  
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10-day institute visits. 
 
You asked the Plan to pre-approve 10-day institute visits. You say that you are requesting 10-day institute 
visits. You say that you have included the most recent therapy notes for review. The Plan denied your request. 
The Plan says the request is a billing preference for the provider; therefore, it is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 10 day institute visits. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found that the enrollee has had extensive physical therapy and 
occupational therapy and was trained in a home exercise program. Our reviewer says that the documentation 
does not reveal a clear rationale that therapy only at the Day Institute is medically necessary for treatment.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 10-day institute visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 10-day institute visits.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve left lateral lumbar interbody fusion L2-3, L3-4 for the 
enrollee. 
 
You asked the Plan to pre-approve the surgery. You say that conservative treatment was denied by the plan. 
The Plan denied your request. The Plan says there has been no documentation of three months of non-operative 
conservative treatments, such as physical therapy, home exercise program, yoga, and/or injections. 
 
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 surgery. Our reviewer says that the 
requested surgery is not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is no recent trial and failure of PT. There is no documented spinal instability. Fusion surgery 
criteria is not met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve left lateral lumbar interbody fusion L2-3, L3-4 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power mobility scooter. 
 
You asked the Plan to pre-approve the scooter. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is being requested for community activities. 
 
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 scooter. Our reviewer says that the 
requested scooter is not medically reasonable or necessary. Our physician reviewer found there is no 
documentation of a personal mobility deficit that impairs participation in MRADLs in the home. Your mobility 
deficit is helped by a walker currently. The documentation does not contain an in-person assessment in the 
home to evaluate that you can safely maneuver the scooter. 
 
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 scooter have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power mobility scooter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the upper and lower partial denture (D5225 and D5226). 
 
You asked the Plan to pre-approve the upper and lower partial denture (D5225 and D5226). You say that the 
work should have been covered by your 2019 benefits leaving remaining benefits from 2020. You say that you 
were under the impression the work would be covered. The Plan denied your request. The Plan says the 
services exceed the maximum count allowed. 
 
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, you also have a maximum benefit of 
one upper and lower partial denture every 5 plan years. The Plan paid for an upper and lower partial denture 
provided on February 11, 2019, which exhausted your benefit. Therefore, we decided that the Plan does not 
have to pre-approve the upper and lower partial denture (D5225 and D5226).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a porcelain-fused crown. 
 
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 that the services do not meet the criteria for coverage. 
 
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 states that the services do not meet the criteria for coverage; however, 
no medical records were submitted with the case file to support this determination. The file shows that records 
were received from the participating provider. MAXIMUS requested these records, but a response was not 
received. Therefore, we decided that the Plan has to pre-approve a porcelain-fused crown.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (99213) to be rendered by the out of 
network (OON) provider. 
 
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 there are available providers within the network that can 
provide the service requested. 
 
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 service at issue in this appeal. We found no exception that would require the 
Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve an office 
visit (99213) to be rendered by the out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cup holder for a Power Mobility Device (K0108). 
 
You asked the Plan to pre-approve the cup holder. You say that this accessory is medically necessary. The Plan 
denied your request. The Plan says the self-leveling cup holder is not medical in nature and is therefore non-
covered. 
 
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 cup holder for a Power Mobility Device (K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a reaching/grabbing device (A9281). 
 
You asked the Plan to pre-approve a reaching/grabbing device. You say that you need this due to your limited 
mobility. The Plan denied your request. The Plan says this is not primarily 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 reaching/grabbing device (A9281).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services (D3425, D3428, D3430). 
 
You asked the Plan to pre-approve the dental 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 services are not among 
those covered under this benefit. The Plan covers only those dental services for which the codes are listed in 
the Evidence of Coverage. Dental codes D3425, D3428, and D3430 are not listed, and therefore, are not 
covered. Therefore, we decided that the Plan does not have to pre-approve dental services (D3425, D3428, 
D3430).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tooth extraction. 
 
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. The extraction is not covered by your medical benefit because it is not 
being done to prepare the jaw for radiation treatment. Therefore, we decided that the Plan does not have to pre-
approve a tooth extraction.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom fabricated ankle-foot orthosis for the enrollee. 
 
You asked the Plan to pre-approve the orthosis. You say that this is medically necessary. The Plan denied your 
request. The Plan says the clinical note does not show that the enrollee has tried and failed a standard brace. 
 
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 orthosis. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found as there is no documented failure to respond to a prefabricated ankle orthosis, this request is not 
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 the orthosis have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a custom fabricated ankle-foot orthosis for the enrollee.