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

 
We decided that the Plan has to pre-approve a positron emission tomography (PET) with concurrently acquired 
computed tomography (CT) scan from the skull to mid-thigh (78815). 
 
You asked the Plan to pre-approve a PET CT scan from the skull to mid-thigh. You say that the services are 
necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage 
criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 a PET CT scan from the skull to mid-
thigh. Our reviewer says that the services are medically necessary. Our physician reviewer found the requested 
PET/CT is more than routine follow-up as the enrollee has symptoms of both hip pain and a history of vertebral 
osteomyelitis the latter of which is possibly indolent and incompletely treated. For these two reasons the 
requested PET/CT is both reasonable and 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 a PET CT scan from the skull to mid-thigh have been met. Therefore, we 
decided that the Plan has to pre-approve a positron emission tomography (PET) with concurrently acquired 
computed tomography (CT) scan from the skull to mid-thigh (78815).  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the interim caries arresting medicament application provided 
on August 19, 2020. 
 
You asked the Plan to pay for the interim caries arresting medicament application. You say that you chose to 
go with the alternative to save your tooth. You also say that the chemical used to fix your tooth appears to have 
saved your tooth. The Plan denied your request. The Plan says this service is not covered under 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 pay for the 
interim caries arresting medicament application provided on August 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cardiac pacemaker for the enrollee. 
 
You asked the Plan to pre-approve the pacemaker. You say that this is medically necessary. The Plan denied 
your request. The Plan says exercise treatment will offer pertinent information regarding the medical necessity 
for a pacemaker. 
 
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 pacemaker. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has mild sinus bradycardia and no symptoms of syncope or significant presyncope. 
In this circumstance, the documentation does not support the medical necessity for pacemaker placement. 
Coverage criteria are not met since there are no documented covered indications for the procedure. Specifically 
there are no documented symptoms that correlate with mild sinus bradycardia identified. 
 
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 pacemaker have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a cardiac pacemaker for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve echocardiography, transthoracic, real-time with image 
documentation (2D), includes M-mode recording, when performed, complete, with spectral Doppler 
echocardiography, and with color flow Doppler echocardiography (CPT Code 93306). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says the service is not 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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the reviewed documentation indicates that there are no cardiac symptoms and the patient?s 
cardiac exam was normal. The submitted documentation does not note any significant changes in the patient?s 
clinical status, such as ECG changes or new / worsening cardiac signs or symptoms, such as chest pain or 
shortness of breath and/or swelling in the lower extremities. There is no clinical rationale for the requested 
echocardiogram. The review has determined that the requested  echocardiography, transthoracic, real-time with 
image documentation (2D), includes M-mode recording, when performed, complete, with spectral Doppler 
echocardiography, and with color flow Doppler echocardiography (CPT Code 93306) is not medically 
necessary or reasonable. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve echocardiography, transthoracic, real-time with image documentation (2D), includes M-
mode recording, when performed, complete, with spectral Doppler echocardiography, and with color flow 
Doppler echocardiography (CPT Code 93306).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the enteral supplies provided from March 6, 2020, to March 
12, 2020. 
 
You asked the Plan to pay for Parenteral nutrition solution (B4185, B4199). You say that the Plan should pay 
this claim. The Plan denied your request. The Plan says the documentation submitted did not include a valid 
physician order. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order for the supplies provided in this case. The physician order 
submitted is dated after the date of service. The record shows that the Plan made several attempts to obtain the 
necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the 
enteral supplies provided from March 6, 2020, to March 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuous glucose monitor supplies to be provider by a 
non-preferred provider. 
 
You asked the Plan to pre-approve the requested items. The Plan denied your request. The Plan says the 
enrollee's benefit does not cover diabetic supplies from a local or mail order pharmacy. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that Supplies to monitor your blood glucose may be limited to supplies from select manufacturers. 
 
The file shows that a continuous glucose monitor receiver was requested. The requested supplier in this case is 
not a network provider with the Plan. The Plan has network providers available who can provide the items at 
issue in this appeal. We found no exception that would require the Plan to pre-approve these items from a non-
preferred supplier. Therefore, we decided that the Plan does not have to pre-approve continuous glucose 
monitor supplies to be provider by a non-preferred provider.
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 stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
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 patient'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 an abdominal abscess after recent surgery. Medical problems are stable. There are no identified 
problems that need inpatient medical management. There are no complex nursing or rehabilitation needs. The 
patient does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. The medical record supports a need for physical and 
occupational therapy but it does not support a need for an intensive rehabilitation therapy program. 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 pre-approve acute IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve upper and lower dentures. 
 
You asked the Plan to pre-approve the dentures. You say that this is medically necessary. The Plan denied your 
request. The Plan says this 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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
upper and lower dentures.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. 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 care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found based on the medical records provided there is 
no documentation that you require skilled nursing services, i.e., the specialized skill, knowledge and judgment 
of a skilled professional nurse is not required to safely and effectively provide medically necessary and 
reasonable treatment. You do require skilled therapy services, i.e., the specialized skill, knowledge and 
judgment of a qualified therapist is required to safely and effectively provide medically necessary and 
reasonable treatment. Daily skilled services are not required. You do not require the services on an inpatient 
basis, in a skilled nursing facility setting. Services in a long-term care facility on a part time basis appear 
appropriate in this case. 
  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a CT scan provided by a participating 
provider on June 29, 2020. 
 
You asked the Plan to waive the copayment for a CT scan. You say that this copayment is too high. The Plan 
denied your request. The Plan says the correct copayment has been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $155 
copayment for outpatient diagnostic tests/radiological diagnostic services.  
 
You have been asked to pay $131.35 which is less than your copayment amount of $155 for a CT scan. A CT 
scan falls within the outpatient diagnostic tests/radiological diagnostic services 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 a CT scan provided by a participating provider on June 29, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a colonoscopy provided on June 11, 2020. 
 
You asked the Plan to waive the copayment for a colonoscopy. You say that you are unhappy with the 
Cologuard test results and had extra stress due to it. The Plan denied your request. The Plan says the claims 
were processed correctly and you are being charged the correct amount. 
 
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 $325 
copayment for outpatient surgery.  
 
You received a colonoscopy on June 11, 2020, due to a positive Cologuard test. Therefore, the colonoscopy is 
considered diagnostic, not preventative. Therefore, you are responsible to pay the $325 copayment.  
 
You have been asked to pay a $325 copayment for a colonoscopy. A colonoscopy falls within the outpatient 
surgery 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 a colonoscopy provided on 
June 11, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF). 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the care could be received in another setting. 
 
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 based on the medical records provided, the complexity of your nursing, medical and 
rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. You do not require an intensive rehab program. Care at the skilled nursing facility level or 
in the home with home health services appears to be more appropriate in this case. 
 
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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle Libre continuous glucose monitoring system. 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says the clinical indicates you receive basal and bolus insulin, and requires frequent 
adjustment. The Plan states this device will not be used by you, but by the facility staff and for this purpose, a 
standard glucometer can be used. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based 
on the blood glucose testing results. 
 
We looked at the file and Medicare rules. The clinical indicates you receive basal and bolus insulin, and 
requires frequent adjustment. The Plan states this device will not be used by you, but by the facility staff. Based 
on this information, we decided that Medicare rules for coverage of the DME have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Freestyle Libre continuous glucose monitoring system.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the Esophagogastroduodenoscopy (EGD) 
with biopsy services provided on August 21, 2020. 
 
You asked the Plan to waive the copayment for the EGD with biopsy. You say that you feel you should not be 
responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied 
your request. The Plan says you received an outpatient surgical procedure on the date of service at issue in this 
appeal. The Plan says that the correct copayment has applied per your contract with the Plan. 
 
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 $350 
copayment for Outpatient surgery.  
 
We looked at the file, the Plan contract and Medicare rules. The file shows that you received an EGD with 
biopsy provided in an outpatient hospital setting on August 21, 2020. You have been asked to pay a $350 
copayment for the EGD with biopsy. The EGD with biopsy falls within the Outpatient surgery 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 the Esophagogastroduodenoscopy (EGD) with 
biopsy services provided on August 21, 2020.  
 
Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus 
Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the 
appropriate Quality Improvement Organization for further review.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says there is not enough medical evidence to show that the procedure is safe and 
helpful. 
 
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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this is an experimental/investigational procedure. Therefore, the request is considered not 
medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Intracept procedure for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve (enteral nutrition) for the enrollee. 
 
You asked the Plan to pre-approve the item. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no documentation of motility or anatomic issues. 
 
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 item. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found weight loss in and of itself is not a diagnosis to support enteral feedings. The product is over the counter. 
 
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 item have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Boost (enteral nutrition) for the enrollee.