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

 
We decided that the Plan does not have to pre-approve an extracapsular cataract removal. 
 You asked the Plan to pre-approve the requested services. You say that you cannot see from the eye. The Plan 
denied your request. The Plan says you do not have vision change that is not correctable with new corrective 
lenses. 
 
The Plan follows Medicare rules. Medicare rules say that cataract surgery is only covered under certain medical 
indications.  
 
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 requested services. Our physician 
reviewer found that you have age-related nuclear cataract, right eye. You reported that the vision in your right 
eye is much blurrier than the left, and that you can no longer have the right eye corrected with a contact lens. It 
is documented that the vision in your right eye is 20/20 -2, and 20/40 with glare. Vision with both eyes was 
20/20. You were counseled that cataract do not require treatment unless they interfere with vision and impact 
one's activities of daily living. The documentation does not support that you meet the coverage criteria. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an extracapsular cataract removal.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an annual wellness visit provided on May 24, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for an annual wellness visit. You say that you would like to request reconsideration 
of the denied claim. The Plan denied your request. The Plan says the provider is out-of-network and 
authorization is required prior to an out-of-network visit. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. 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 an annual wellness visit provided on May 24, 
2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided from July 14, 2021, 
to July 17, 2021. 
 
You asked the Plan to pay for the services provided. You say that the provider's statement is sufficient for 
reporting. The Plan denied your request. The Plan says the diagnosis code is not consistent with the records. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services with principal diagnosis code, A41.59, defined as other gram-
negative sepsis. 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 the services provided. Our 
physician reviewer found that the enrollee presented to the emergency room and was found to have pneumonia. 
After fluid resuscitation and treatment, there was no documented platelet count less than 150, 000. There was 
no documented total bilirubin level of 1.2 mg/dL or greater. There was no documented mean arterial pressure 
less than 70 mmHg or less, and no hypotension or hemodynamic instability. The review has determined that the 
diagnosis code was not consistent with the records.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for the inpatient hospital services provided from July 14, 2021, to July 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Fasenra Pen injection 30 mg/ml. 
 
You asked the Plan to pre-approve the Fasenra Pen. You say that please see attached prior authorization form 
and clinicals. The Plan denied your request. The Plan says coverage is not available under Part B if the drug is 
not given and supplied by the physician. The Plan does not cover outpatient prescription drugs. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve the Fasenra Pen injection 30 mg/ml.  
 
Benefits for the Fasenra Pen 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a Positron Emission Tomography (PET) scan prostate cancer.
You asked the Plan to provide coverage for a PET scan. You say that a PET scan is medically necessary. The Plan denied your request. The Plan says PET scans are excluded from coverage for prostate cancer. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not follow the Medicare guidelines.
The Plan is correct in this case. Medicare does not cover initial anti-tumor treatment strategy in Medicare beneficiaries who have adenocarcinoma of the prostate. Your physician ordered a PET scan due to family history and to determine if initial stating was necessary. While this may or may not have beneficial it simply is not covered imaging by Medicare at this time. Therefore, we decided that the Plan does not have to provide coverage for a Positron Emission Tomography (PET) scan prostate cancer.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that this item is medically necessary for your 
condition. The Plan denied your request. The Plan says this item is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Oxycodone. 
 
You asked the Plan to pre-approve Oxycodone. You say that the enrollee gets the most pain relief from 
Oxycodone due to the severity of her pain. The Plan denied your request. The Plan says the requested 
medication does not fall under Part B coverage. The Plan says that the enrollee does not have pharmacy 
benefits administered under this contract. 
 
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 Oxycodone.  
 Benefits for Oxycodone 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are requesting LTACH services for 
the enrollee. The Plan denied your request. The Plan says the current acute care facility can provide acute care 
services until the member's condition allows transfer to an alternate level of care, such as skilled nursing 
facility, acute inpatient rehabilitation, home health care, nursing home, or home. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where the 
enrollee is currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a right breast prosthesis (L8020). 
 
You asked the Plan to pre-approve a right breast prosthesis. You say that you are a breast cancer/post 
mastectomy patient who wears a silicone prosthesis but also likes to wear the lighter weight leisure forms. It is 
a necessity when you have to wear these daily. The Plan denied your request. The Plan says you were 
previously approved for a right breast prosthesis on 6/2/2021, and these items have a 2-year reasonable useful 
lifetime. No documentation has been provided that your current breast prosthesis has been damaged rendering 
it unusable. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare will pay for only one breast prosthesis 
per side for the useful lifetime of the prosthesis. 
 
 
 
 We looked at the file and Medicare rules. The records show you received a right breast prosthesis in June of 
2021. The LCD confirms that you have a 2-year reasonable useful lifetime on that item. Based on this 
information, we decided that Medicare rules for coverage of a right breast prosthesis have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a right breast prosthesis (L8020).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the 
Plan's 36-trip limit. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you need transportation to 
appointments. The Plan denied your request. The Plan says you have exhausted your transportation benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 36 trips per year.  
 
 We looked at your request, the records in the case file, and the rules. The Plan has provided documentation 
showing that 36 transports have already been covered. Based on this information, we decided that you have 
exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the 
Plan does not have to pre-approve additional trips for routine transportation beyond the Plan's 36-trip limit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee needs this Astro vent for 
recurrent hospitalizations for hypercapnic respiratory failure from COPD, diastolic CHF and obesity 
hypoventilation syndrome. The Plan denied your request. The Plan says claims for ventilators used to provide 
CPAP or bi-level CPAP therapy for conditions described in this RAD policy will be denied as not reasonable 
and necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 
 
 
 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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has a diagnosis of COPD 
with frequent hospitalizations requiring ventilatory support. ABGs are consistent with acute on chronic 
hypercarbic respiratory failure. The enrollee is likely to benefit from BiPAP with AVAPS during sleep as an 
outpatient. Medicare does not cover a home ventilator when used as BiPAP. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet injections coded as 64490, 64491 and 64492. 
 
You asked the Plan to pre-approve facet injections. You say that the medical records provided support the 
necessity of the services in dispute. The Plan denied your request. The Plan says the enrollee does not meet the 
medically necessary criteria. 
 
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 facet injections. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the review indicates that the enrollee has a diagnosis of myalgia of auxiliary muscles, head and 
neck. Clinical notes show the enrollee with chronic pain up to 8/10 neck pain with elements of radiation to the 
right arm and trapezius. The enrollee has tried medications with some relief and physical therapy with 
worsening of her symptoms. Electromyography testing confirms cervical radiculopathy. There is facet 
arthropathy on cervical x-rays and degenerative changes on the MRI. The records do not show that the enrollee 
meets the medically reasonable and necessary criteria for Medicare coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve facet injections coded as 64490, 64491 and 64492.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox. 
 
You asked the Plan to pre-approve Botox. You say that this drug is medically reasonable and necessary for the 
enrollee's condition. The Plan denied your request. The Plan says step therapy criteria have not been met. 
 
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 Botox. Our reviewer says that the 
requested drug is not medically reasonable and necessary. Our physician reviewer found the Plan requires a 
trial of Xeomin before they will approve the requested drug. In this case, the patient has not tried and failed the 
required drug. There is no documentation provided indicating that the plans required drug would likely be less 
effective and/or likely have adverse effects for the 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 Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Botox.
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 the therapy. You say that this is medically necessary. The Plan denied your 
request. The Plan says the notes show that the enrollee is ready for a home program. 
 
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 therapy. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the progress is limited secondary to nerve damage. Progress after more than a year will be very slow 
and depend upon nerve regeneration not therapy. She is able to do a home exercise program. Continued input 
from a skilled therapist is not necessary to restore or maintain function. The enrollee is receiving a repetitive 
therapy program. Continued working of hands and shoulder is appropriate but does not require continued 
skilled input. 
 
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 therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve physical therapy.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (G0480, 80307, 84228, 82542) 
provided on May 10, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they were 
non-emergent and 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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. 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 laboratory services (G0480, 80307, 84228, 
82542) provided on May 10, 2022 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory services (81479) billed for date of service March 12, 2022. 
 
You asked the Plan to pay for laboratory services. You say that these services were necessary and are supported 
in the medical record. The Plan denied your request. The Plan says that the date of service reported for a 
clinical laboratory test or the technical component of a physician pathology service must be the date the 
specimen was collected. The specimen was collected on February 3, 2022, rather than the billed date of service 
of March 12, 2022. Therefore, this service is denied. 
 
The Plan must follow Medicare rules. The rules say that generally, laboratory claims should be submitted with 
the date the specimen was collected as the date of service. However, there are exceptions to this rule. The rules 
also say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE 
information regarding its decision to deny coverage or payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has applied a rule without acknowledging the possible 
exceptions or providing any argument to show that an exception has not been met. Based on the documentation 
provided, it appears that the sample in question was likely obtained during an outpatient hospital procedure and 
would have been inappropriate to collect outside of this procedure. It does not appear that the results of this test 
would have affected the enrollees hospital care at the time of collection. This means that exception 2 would be 
met and the appropriate date of service in this case would be the date the testing was performed. The Plans 
denial is not substantiated in this case. Therefore, we decided that the Plan has to pay for laboratory services 
(81479) billed for date of service March 12, 2022.  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 further reimbursement for eyeglasses purchased on November 12, 2021.
You asked the Plan to pay more of the cost of this eyewear. The Plan denied your request. The Plan says the maximum $300 benefit was applied. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not interpret the case correctly. The Plan demonstrated that the claim from the vision provider processed with a payment of $180 to the provider and with a $100 enrollee liability. In addition, the Plan applied $325 towards the cost of the eyeglasses. The Explanation of Benefits shows $425 was charged for the Eyeglasses. There was also a supplement vision discount of $145 applied to this service. The Plan contract clearly states enrollees will be responsible for anything over the $300 retail price.
The Plan is correct in this case. Medicare 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.
The records provided show the Plan actually paid $325, which is more than the maximum benefit and the supplement vision issued a $145 discount. No further payment is due to you for this eyewear. Therefore, we decided that the Plan does not have to pay additional reimbursement for eyeglasses purchased on November 12, 2021.