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

 
We decided that the Plan does not have to pre-approve a cane. 
 
You asked the Plan to pre-approve a cane. You say that your canes are worn out. The Plan denied your request. 
The Plan says you can receive one cane every 5 years. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
We looked at the file and Medicare rules. The file shows that you received 2 canes in July 2018. The requested 
cane services the same purpose as your current canes. The records provided do not show that your current 
cane(s) are of irreparable damage. Based on this information, we decided that Medicare rules for coverage of a 
cane have not been met. Therefore, we decided that the Plan does not have to pre-approve a cane.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the oral exams (D0120), prophylaxis (D1110), and bitewing x-rays (D0274) provided on March 30, 2021, and October 14, 2021.
You asked the Plan to reimburse you for these services. You say that you should be reimbursed $303.66 for the dental services you received. The Plan denied your request. The Plan says that the claim is not eligible for reimbursement.
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 says expenses must be submitted by March 31, 2022, or within 90 days of disenrollment with the Plan.
We looked at the file and Plan rules. Though the Plan offers a supplemental benefit in excess of Medicare coverage, the claim was not received on or before the run-out date of March 31, 2022. The record shows that the claim was postmarked April 2, 2022. Therefore, we decided that the Plan does not have to reimburse you for the oral exams (D0120), prophylaxis (D1110), and bitewing x-rays (D0274) provided on March 30, 2021, and October 14, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency 
transport (A0428), and ground mileage (A0425) provided on July 20, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that the services should be covered. The Plan 
denied your request. The Plan says the enrollees claim would be covered under Original Medicare as it is 
responsible for coverage of Part B benefits starting on the date of election until the last day of the month in 
which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage 
before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.  
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on July 16, 2022. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for the ambulance service, 
basic life support, non-emergency transport (A0428), and ground mileage (A0425) provided on July 20, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. You say that you need Euflexxa. The Plan denied your request. 
The Plan says the Plan requires a trial of Orthovisc, Synvisc, or Synvisc-One before it will approve Euflexxa. 
 
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 Euflexxa. Our reviewer says that you 
do not meet criteria for a step therapy exception for Euflexxa. Our physician reviewer found you have not tried 
and failed the Plan's preferred drugs of Orthovisc, Synvisc, or Synvisc-One. The record does not show that 
these drugs would likely be less effective or have adverse effects for you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of Euflexxa.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on February 10, 2022.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial.
The Plan requested a reopen and stated that Maximus did not apply the correct criteria. The Plan notes that this claim was billed with a date of service inconsistent with Medicare rules governing laboratory services. The records submitted show that a specimen was collected on January 20, 2022. There is no documentation of molecular pathology testing performed on the date billed: February 10, 2022. The provider also did not submit the claim with the required "DEX ZCode."
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this case, this claim cannot be paid due to the omission of a required code as well as a discrepancy with the dates of service versus the date the specimen was collected. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on February 10, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Enhertu. 
 
You asked the Plan to pre-approve Enhertu. The Plan denied your request. The Plan says the use of the drug is 
not supported. 
 
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 Enhertu. Our physician reviewer found 
that the enrollee has endometrial cancer. The requested use of Enhertu is not FDA approved for the enrollee's 
condition. The use is not supported by one of the major drug compendia or by clinical research that appears in a 
CMS-approved medical journal. The use of Enhertu for the treatment of endometrial cancer (uterine papillary 
serous carcinoma) does not meet Medicare criteria for 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 Enhertu have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Enhertu.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341) provided 
by a participating provider. 
 
You asked the Plan to pre-approve periodontal scaling and root planing. You say that these services are 
medically necessary. The Plan denied your request. The Plan says these services are not medically necessary. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers periodontal 
scaling and root planing 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 periodontal scaling and root planing. 
Our reviewer says that D4341 is not medically necessary. Our physician reviewer found lack of periodontal 
charting and inconclusive radiographs showing bone loss and calculus deposits are the issue. 
 
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 periodontal scaling and root planing have not been met. Therefore, we decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341) provided by a 
participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive periodontal evaluation-new or established 
patient (D0180) provided on August 10, 2022. 
 
You asked the Plan to pay for dental services. You say that you had an evaluation with your new provider, and 
you do not understand why the service was denied. 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 Plans coverage rules apply in this case. Comprehensive periodontal 
evaluation-new or established patient (D0180) is not covered under the Plans dental benefits under any 
circumstance including seeing an in-network or out-of-network provider. 
 
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 
comprehensive periodontal evaluation-new or established patient (D0180) provided on August 10, 2022.
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 this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says the medical necessity for admission to acute inpatient rehabilitation is not 
met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 enrollees medical problems are stable and there are no complex nursing or rehabilitation needs. There is no documented need for intensive rehabilitation services and medically necessary 
care can be provided in a different level of care. 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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 the cost of a standard intraocular lens (IOL) applied 
toward a non-standard IOL. 
 
You asked the Plan to pre-approve non-standard IOL. You say that you believe Medicare coverage for a 
standard IOL will be applied to the cost of the non-standard IOL, reducing the cost. The Plan denied your 
request. The Plan says Medicare only covers a standard intraocular lens (IOL). 
 
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives a P-C or A-C 
IOL during cataract surgery, the enrollee will be responsible for the difference in cost between the P-C or A-C 
IOL and a conventional IOL. Medicare rules say that for Medicare to consider coverage and payment for any 
item or service, the information submitted by the supplier or provider must corroborate the documentation in 
the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the cost of a standard IOL being 
applied toward a non-standard IOL have been met. Medicare does allow the cost of a standard IOL to be 
applied toward coverage of a presbyopia-correcting (P-C) or astigmatism-correcting (A-C) intraocular lens 
(IOL), with the enrollee paying the difference in cost for the P-C or A-C IOL. However, you have not specified 
the type of unconventional IOL that you are requesting, referring to it only as a non-standard IOL. The Plan 
obtained medical records from your treating physician which also do not include notes related to this requested 
IOL. Without specification of the type of unconventional IOL being requested, we cannot determine whether it 
meets criteria for partial coverage of a P-C or A-C IOL. Therefore, we decided that the Plan does not have to 
pre-approve the cost of a standard intraocular lens (IOL) applied toward a non-standard IOL.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder (ILR) (33285). 
 
You asked the Plan to pre-approve an ILR. You say that the requested service is medically necessary. The Plan 
denied your request. The Plan says the service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an ILR. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found while the enrollee has a history of atrial fibrillation, there is no documentation provided to 
suggest a history of unexplained syncope, cryptogenic stroke or any other apparent indication for an 
implantable loop recorder (ILR). As such, there is insufficient documentation to support the medical necessity 
for insertion of an ILR. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an ILR have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an implantable loop recorder (ILR) (33285).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on August 16, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the evaluation and management service. You say that the service should be 
covered. The Plan denied your request. The Plan says prior authorization was not obtained. 
 
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 provider in this case is not a network provider with the Plan. 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 office visit provided on August 16, 2022, by an out-of-
network (OON) provider.
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 it is medically necessary for the enrollee to receive 
IRF care. The Plan denied your request. The Plan says the Medicare guidelines for IRF admission were not met 
and the enrollee can receive the services that they need at a skilled nursing facility. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
  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 that 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 
enrollee was admitted for gastrointestinal bleeding. Medical problems are stable. 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 supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. 
 
There is not a reasonable expectation that this 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 1 standard, power operated vehicle (K0800). 
 
You asked the Plan to pre-approve a scooter. You say that your hips are really bad, and your legs are weak. 
You also had surgery on your knee which did not help at all, and your neck has nerve damage. For these 
reasons, you need the requested scooter. The Plan denied your request. The Plan says your request is not 
medically necessary because your records do not indicate that you need this scooter to care for yourself in your 
home, nor that a cane, walker, or manual wheelchair couldnt help you. You are described as playing golf. 
Additionally, in your appeal you describe problems walking to your mailbox. Medicare guidelines specifically 
say that scooters to be used only outside the home are not covered. 
 
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 patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 
 The file shows that you do not have a mobility deficit that impairs your participation in MRADLs, and that 
your condition can be improved by a walker, cane or manual wheelchair. This means that Medicare rules for 
coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
group 1 standard, power operated vehicle (K0800).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lumbar 
spine. 
 
You asked the Plan to pre-approve the MRI. You say that an MRI is needed to determine further treatment for 
the enrollee. The Plan denied your request. The Plan says the enrollee has not completed 6 weeks of provider 
directed treatment and there was no contact with the enrollee's provider after completing treatment. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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. Our reviewer says that the 
MRI is not medically necessary and reasonable for the diagnosis and treatment for the enrollee's clinical 
condition at this time. Our physician reviewer found that in this case, the record indicates that the enrollee has 
lumbar radiculopathy in the setting of known spondylosis. The record does not indicate any red flag symptoms 
or abnormal neurological findings. The record documents normal straight leg raising. The record does not 
indicate that the enrollee has tried and failed conservative management. The elements of the coverage criteria 
are not satisfied. The requested service cannot be recommended. 
 
  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 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a magnetic resonance imaging (MRI) of the lumbar spine.
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 this is medically necessary. The Plan denied your 
request. The Plan says this 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 in the Medicare rules section. 
 
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 your medical problems are stable and there are no complex nursing or rehabilitation 
needs. There is no documented need for intensive rehabilitation services and medically necessary care can be 
provided in a different level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.