Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intravenous (IV) Orencia (abatacept) (J0129). 
 
You asked the Plan to pre-approve Orencia. You say that the requested drug is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee has not tried and failed the preferred drug, 
Stelara. 
 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 Orencia. Our reviewer says that the step 
therapy criteria have not been met. Our physician reviewer found the provided documentation does not indicate 
that the enrollee has tried and failed the required drug, Stelara. The reviewer also found that there is no 
indication that the plan's required drug would likely be less effective and/or likely have adverse effects for the 
enrollee. Therefore, the reviewer found that the step therapy criteria have not been 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 Orencia have not been met. Therefore, we decided that the Plan does not have 
to pre-approve intravenous (IV) Orencia (abatacept) (J0129).
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 enrollee's needs cannot be met at a lower level of 
care. The Plan denied your request. The Plan says the services the enrollee needs can be provided safely 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 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 enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you need the inpatient skilled nursing and 
rehabilitation due to this being your seventh knee surgery. You state you have sixteen stairs in your home that 
you cannot manage after your latest surgery. The Plan denied your request. The Plan says this is not medically 
necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section 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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
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 SNF care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an outpatient eye surgery service provided 
on October 19, 2022. 
 
You asked the Plan to reduce the copayment for an eye surgery. You say that you were told that your procedure 
would only have $200 copayment, but you were billed a $350 copayment. The Plan denied your request. The 
Plan says this cost sharing was charged correctly. 
 
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 provided in an outpatient hospital.  
 
You have been asked to pay a $350 copayment for an eye surgery. This item/service falls within the outpatient 
surgery provided in an outpatient hospital 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 reduce the copayment 
for an outpatient eye surgery service provided on October 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 
 
You asked the Plan to pre-approve a CGM. You say that the medical records provided support the need for the 
CGM. The Plan denied your request. The Plan says this service is not medically necessary. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 a CGM. Our reviewer says that the 
service is not medically necessary.  
 Our physician reviewer found the record provided does not indicate that the enrollee's insulin treatment 
regimen requires frequent adjustment by the enrollee on the basis of the testing results. The record provided 
does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested 
service. 
 
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 CGM have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a therapeutic continuous glucose monitor (CGM).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on June 27, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that there is no agreement that the tests should 
be included in the dialysis rate. The Plan denied your request. The Plan says Medicare does not separately pay 
for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate.  
 No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the laboratory services related to end-stage renal disease (ESRD) provided on June 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the transcatheter insertion or replacement of permanent
leadless pacemaker, including imaging guidance and device evaluation (33274) provided on January 19, 2021.
You asked the Plan to pay for this service. You say that this claim should be paid by the Plan. The Plan denied
your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial
stating the enrollee was eligible for this service.
The Plan requested a reopen and stated the issue was not eligibility but the fact that the limited medical records
provided do not confirm the services billed were provided.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that the provider,
supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to
determine whether payment is due and the amount of payment. The records provided are quite limited. There is
insufficient information in the record to determine if this claim was billed appropriately. Medicare billing
criteria were not met as the records provided do not substantiate the services billed. Therefore, we decided the
plan does not have to pay for the transcatheter insertion or replacement of permanent leadless pacemaker,
including imaging guidance and device evaluation (33274) provided on January 19, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound study provided on July 14, 
2022 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you were told that your in-network 
x-ray was covered prior to your visit. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
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 $135 
copayment for Medicare covered outpatient diagnostic radiology services received in an outpatient hospital.  
 
You have been asked to pay $135 copayment for an x-ray. This item/service falls within the Medicare covered 
outpatient diagnostic radiology services received in an outpatient hospital 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 an ultrasound study provided on July 14, 2022
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for intravenous hydration services provided to the enrollee on
May 14, 2020 and billed under code 96360.
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 Medicare coverage criteria were not met. Maximus overturned the Plans denial. The
Plan requested a reopen and stated that Maximus did not apply the correct Medicare criteria. The Plan says that
based on Medicare LCD is based on services rendered in the region.
The services were rendered in a state, therefore the guidelines for LCD L34960 were correctly
applied and this claim cannot be paid as billed.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. Providers must report services with the appropriate codes. In this case, code 96360
was not billed appropriately on this claim. Therefore, we decided that the Plan does not have to pay for
intravenous hydration services provided to the enrollee on May 14, 2020 and billed under code 96360.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Continuous Positive Air Pressure (CPAP) machine 
(E0601). 
 
You asked the Plan to pre-approve the Continuous Positive Air Pressure (CPAP) machine. You say that this 
device is medically necessary. The Plan denied your request. The Plan says the records provided do not support 
that this item is medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a CPAP machine is covered only when the 
beneficiary has an in-person clinical evaluation by the treating practitioner prior to the sleep test to assess the 
beneficiary for obstructive sleep apnea. 
 
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 Continuous Positive Air Pressure 
(CPAP) machine. Our reviewer says that this device is not medically necessary. Our physician reviewer found 
there are no records provided that show a face to face visit with the treating physician prior to the sleep test. 
 
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 Continuous Positive Air Pressure (CPAP) machine have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Continuous Positive Air Pressure (CPAP) 
machine (E0601).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pacemaker battery replacement, to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a pacemaker battery replacement. You say that the service is medically 
necessary. The Plan denied your request. The Plan says there are in-network providers that can perform this 
service. 
 
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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a pacemaker battery replacement, to be provided by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF care provided from November 1, 2021, to November 
12, 2021. 
 You asked the Plan to pay for SNF care. You say that this was medically necessary for the enrollee. The Plan 
denied your request. The Plan says criteria has not been met, there are no records submitted to show daily 
skilled services, either nursing or therapy were provided. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section 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 pay for SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
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 pay for SNF care provided from November 1, 2021, to November 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the SSBCI benefits. 
 
You asked the Plan to pre-approve the SSBCI benefits. You say that you have more than one qualifying 
condition to be eligible for the SSBCI benefits. The Plan denied your request. The Plan says you do not meet 
the criteria to be eligible for SSBCI benefits. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the SSBCI benefits have not been met. Specifically, we have confirmed that you do not have one 
of the eligible conditions listed in the Evidence of Coverage. Therefore, we decided that the Plan does not have 
to pre-approve the SSBCI benefits.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the upper 
extremity. 
 
You asked the Plan to pre-approve the MRI. You say that the MRI is medically necessary. The Plan denied 
your request. The Plan says the documentation does not show 6 weeks of conservative care. 
 
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 of the upper extremity is not medically necessary. Our physician reviewer found that the records indicates 
that the enrollee has shoulder pain and decreased range of motion. The record does not indicate the presence of 
any red flag symptoms or neurological signs. The record does not indicate the failure of a trial of physical 
therapy. The requested service is not medically necessary and reasonable for the diagnosis and treatment for the 
enrollee's clinical condition at this time. The elements of the coverage criteria are not satisfied. 
 
  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 upper extremity.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve external upper limb tremor stimulator of the peripheral 
nerves of the wrist (Cala Trio device) (K1018), and replacement supplies and accessories (K1019). 
 
You asked the Plan to pre-approve Cala Trio device. You say that your doctor gave you a prescription for the 
Cala Trio device. You also say that the only other option is surgery. The Plan denied your request. The Plan 
says the requested items are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that while electric nerve stimulation has been employed to 
control chronic intractable pain for some time, its use in the treatment of motor function disorders, such as 
multiple sclerosis, is a recent innovation, and the medical effectiveness of such therapy has not been verified by 
scientifically controlled studies. 
 
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 Cala Trio device. Our reviewer says 
that the Cala Trio device is not medically necessary. Our physician reviewer found the provided records do not 
clarify that all medications (such as duloxetine which is listed as a current medication) or other substances 
(such as caffeine) that could be exacerbating the tremor have been discontinued. Therefore, the reviewer found that the requested device is not medically reasonable or necessary 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 Cala Trio device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve external upper limb tremor stimulator of the peripheral nerves of the wrist (Cala Trio 
device) (K1018), and replacement supplies and accessories (K1019).
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the bone graft at time of implant placement (D6104), and 
surgical placement of implant body: endosteal implant (D6010). We decided that the Plan does not have to 
pre-approve the guided tissue regeneration - resorbable barrier, per site (D4266).  
 
You asked the Plan to pre-approve the guided tissue regeneration - resorbable barrier, per site (D4266), bone 
graft at time of implant placement tooth #'s 19 and 30 (D6104), and surgical placement of implant body: 
endosteal implant tooth #'s 19 and 30 (D6010). You say that the implant was recommended because you have 
lingual torus and are a good candidate for the procedure. You also say that you cannot use dentures due to 
lingual torus. The Plan says that these services are not medically necessary. 
 
We also decided that the Plan does not have to pre-approve the guided tissue regeneration - resorbable 
barrier, per site (D4266) . 
 
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.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the guided tissue regeneration - 
resorbable barrier, per site (D4266) is not among those covered under this benefit. Therefore, we decided that 
the Plan does not have to pre-approve the guided tissue regeneration - resorbable barrier, per site (D4266). 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel testing provided on May 16, 2022. 
 
You asked the Plan to pay for the testing services. You say that the treatment sought was medically necessary. 
The Plan denied your request. The Plan says one code must be submitted for the panel. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
 We find that the panel testing was not billed with a single code as required. Based on this information, we 
decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that 
the Plan does not have to pay for the gene panel testing provided on May 16, 2022.