Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a routine eye exam (92002) received on May 18, 2020, and a 
portion ($106.90) of the cost of eyeglass frames (V2020) purchased on August 21, 2020. 
 
You asked the Plan to pay for a routine eye exam and a portion ($106.90) of the cost of eyeglass frames. You 
say that you did not realize your vision care provider does not accept coverage under the Plan. The Plan denied 
your request. The Plan says rules for payment have not been met. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. 
 
Regarding the request to pay for a portion ($106.90) of the cost of eyeglass frames: 
 
We looked at the file and the Plan's rules. The Plan provides a $200 allowance for supplemental eyewear every 
year. The Plan has agreed to pay for eyeglass frames up to the annual allowance amount ($200). The Plan 
contract states that enrollees are responsible for all costs over and above the allowance amount. Based on this 
information, we decided that the Plan's rules for coverage of a routine eye exam and a portion ($106.90) of the 
cost of eyeglass frames have not been met.  
 
Regarding the request to pay for a routine eye exam: 
 
The Plan does not cover routine eye exams. We decided that the Plan's rules for coverage of a routine eye exam 
have not been met. 
 
Therefore, we decided that the Plan does not have to pay for a routine eye exam (92002) received on May 18, 
2020, and a portion ($106.90) of the cost of eyeglass frames (V2020) purchased on August 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the full physical provided on October 13, 2020. 
 
You asked the Plan to pay for the full physical. You say that you feel that this should be covered because this 
was a wellness check that is required by the Plan. The Plan should have known that you had the physical exam 
in Florida and told your New York doctor not to provide this. The Plan denied your request. The Plan says you 
were provided with an annual physical in February 2020. Your other doctor then provided a second full 
physical which cannot be covered twice in the year. 
 
The Plan must follow Medicare rules. Medicare rules say that Plans may cover certain supplemental benefits 
that are not covered by Original Medicare. Your Plan covers one annual physical which is more comprehensive 
than the Medicare annual wellness visit. 
 
In this case, your second annual physical was provided by a doctor not associated with the Florida PCP who 
provided the February physical. There is no evidence that you were told this would solely be an annual 
wellness visit or that you informed the provider that you had already received your full physical for the year. 
Therefore, we decided that the Plan does not have to pay for the full physical provided on October 13, 2020.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Erbitux. 
 
You asked the Plan to pre-approve Erbitux. You say that the enrollee is Cisplatin ineligible. The Plan denied 
your request. The Plan says that there are alternative treatments for the enrollee's condition. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Erbitux. Our physician reviewer found 
that the enrollee has laryngeal cancer. The requested use of the drug is supported by the National 
Comprehensive Cancer Network (NCCN) compendium. The documentation does support that the requested 
drug is safe and effective, and otherwise reasonable and necessary for this enrollee 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Erbitux have been met. Therefore, we decided that the Plan has to pre-approve 
Erbitux.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

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

 
We decided that the Plan does not have to pre-approve Valacyclovir. 
 
You asked the Plan to pre-approve Valacyclovir. You say that the medication is necessary. The Plan denied 
your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Valacyclovir.  
 
Benefits for Valacyclovir 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve placement of the Superion interspinous spacer. 
 
You asked the Plan to pre-approve the Superion procedure. You say that Original Medicare covers this 
procedure so the plan should not be denying this. The Plan denied your request. The Plan says there is not 
sufficient evidence to support the medical necessity of this procedure over standard treatments. 
 
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 Superion procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the spacer is considered 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 Superion procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve placement of the Superion interspinous spacer.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial inpatient hospital care (99222) provided August 19, 
2019. 
 
You asked the Plan to pay for the inpatient hospital care. You say that please note you did not receive proper 
notice of this enrollee's benefit determination hence, the untimely submission of the claim. The Plan denied 
your request. The Plan says claim was submitted after the timely filing limitations. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the inpatient hospital care was not filed until September 18, 2020. This 
means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for initial inpatient hospital care (99222) provided 
August 19, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Transcatheter Aortic Valve Replacement (TAVR) 
procedure (33361) provided on October 17, 2019. 
 
You asked the Plan to pay for a TAVR procedure. You say that this was medically necessary. The Plan denied 
your request. The Plan says the records does not show that the enrollee was in a clinical trial. 
 
The Plan must follow Medicare rules. Medicare rules say that the Centers for Medicare & Medicaid Services 
(CMS) covers transcatheter aortic valve replacement (TAVR) under Coverage with Evidence Development 
(CED) with additional conditions. 
 
We looked at the file and Medicare rules. The submitted records do not include the number of a clinical trial 
that the enrollee is enrolled in. Based on this information, we decided that Medicare rules for coverage of a 
TAVR procedure have not been met. Therefore, we decided that the Plan does not have to pay for a 
Transcatheter Aortic Valve Replacement (TAVR) procedure (33361) provided on October 17, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crown-porcelain fused to high noble metal to tooth #8 
and #10 (D2750). 
 
You asked the Plan to pre-approve crown. You say that the service is medically necessary. The Plan denied 
your request. The Plan says the service is not medically necessary or reasonable. 
 
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 crowns 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 crown. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found crowns may need replacement when they 
have decayed margins or substantial porcelain fractures that cause food impaction issues. Given the provided 
documentation, there is no clear reason or necessity for replacement of either #8 or #10 crowns. 
 
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 crown have not been met. Specifically, the service requested is not medically 
necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve crown-porcelain 
fused to high noble metal to tooth #8 and #10 (D2750).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a delivery service charge (99070) and sales tax (S9999) 
provided on January 2, 2020. 
 
You asked the Plan to pay for a delivery service charge and sales tax. You say that this should be covered. The 
Plan denied your request. The Plan says these charges are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that MACs do not make any additional payment for 
sales taxes or separate delivery and service charges. 
 
We looked at the file and Medicare rules. These charges are not separately payable. Based on this information, 
we decided that Medicare rules for coverage of a delivery service charge and sales tax have not been met. 
Therefore, we decided that the Plan does not have to pay for a delivery service charge (99070) and sales tax 
(S9999) provided on January 2, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for prostate surgery and hospital services received outside the 
country on May 26 to June 23, 2019. 
 
You asked the Plan to pay for prostate surgery and hospital services. You say that the requested services were 
emergent and medically necessary. The Plan denied your request. The Plan says rules for payment have not 
been met. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for prostate surgery and hospital services was not received until August 26, 
2020. This means that more than one calendar year from the date of service had passed before a claim was 
filed. Therefore, we decided that the Plan does not have to pay for prostate surgery and hospital services 
received outside the country on May 26 to June 23, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lead wires, per pair (A4557) provided. 
 
You asked the Plan to pay for the lead wires. You say that per CMS LCD L33802, A4557 is not inclusive to 
A4595 and is separately reimbursable. The Plan denied your request. The Plan says this service is not allowed 
because it is included in another service provided at the same time or within one year period. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. A tens unit was purchased in the previous 12 months. Records 
supporting the medical necessity of additional lead wires were not submitted. Based on this information, we 
decided that Medicare rules for coverage of the lead wires have not been met. Therefore, we decided that the 
Plan does not have to pay for the lead wires, per pair (A4557) provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sacroiliac joint radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve the services. You say that you have had this procedure previously. The Plan 
denied your request. The Plan says this is considered investigational. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found SI joint ablation is experimental. More research is needed to show safety and efficacy. The use of 
radiofrequency ablation for pain management related to sacroiliitis has not been shown to provide clear long-
term benefit than standard treatment for chronic sacroiliac joint pain. Based upon the review of the medical 
literature, radiofrequency ablation used for sacroiliac joint pain is considered experimental and not medically 
necessary whether using traditional, cooled, or pulsed radiofrequency. The review has determined that the 
requested RFA at issue is 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve sacroiliac joint radiofrequency ablation (RFA).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Vitamin D assay rendered on July 9, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the testing is not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The test at issue in this appeal, a Vitamin D assay, was requested solely for screening purposes. Medicare does 
not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for 
the Vitamin D assay rendered on July 9, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS HF System. 
 
You asked the Plan to pre-approve a CardioMEMS HF System. 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 CardioMEMS HF System. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found in this circumstance therapy change based on data obtained from a 
CardioMEMs device has been demonstrated in only one randomized prospective trial to help reduce hospital 
readmission compared to standard medical therapy. Moreover, concerns have been raised about potential bias 
in this trial calling into question the results. Therefore, 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. Medicare coverage criteria are not met since the device should still be considered experimental or 
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 a CardioMEMS HF System have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a CardioMEMS HF System.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy. 
 
You asked the Plan to pre-approve physical therapy. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 physical therapy. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of your 
condition. Our physician reviewer found the requested services are not part of a maintenance program, and the 
specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or 
deliver a program to maintain your current condition or to prevent or slow further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physical therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve physical therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services rendered on August 28, 2019. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for these services was not filed until November 5, 2020. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for the services rendered on August 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and x-ray rendered on October 13, 2020. 
 
You asked the Plan to pay for 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 say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. The provider submitted a 
claim for procedure code 99203 (office visit) and 72040 (cervical spine x-ray). These services are not covered 
when billed by a chiropractor. Therefore, we decided that the Plan does not have to pay for the office visit and 
x-ray rendered on October 13, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan does not have to pay forgenetic testing provided to the enrollee on August 12, 2020.You asked the Plan to pay forthis service. You say that these services should be covered by the Plan.The Plan denied your request. The Plan says this provider is not a Medicare eligible provider. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional information to confirm the providers Medicare status.The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program.Therefore, we decided that the Plan does not have to pay forgenetic testing provided to the enrollee on August 12, 2020.