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

 
We decided that the Plan does not have to pre-approve SNF services. 
 
You asked the Plan to pre-approve SNF services. You say that the daily progress notes from the attending 
medical team and the most recent notes from physical and occupational therapy support the request for SNF 
services. The Plan denied your request. The Plan says the enrollee does not need daily skilled therapy or 
nursing services. 
  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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that the provided records do not 
document a significant decline in the enrollees functional status to necessitate daily inpatient skilled therapy 
services. Services with home health care or in a long-term care facility on a part time basis are 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve SNF services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve a portable ventilator. 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 follows Medicare rules. Medicare rules say that the Centers for Medicare & Medicaid Services 
(CMS) National Coverage Determinations Manual (CMS Pub. 100-03) in Chapter 1, Part 4, Section 280.1 
stipulates that ventilators (E0465, E0466, and E0467) are covered when specific criteria are met. 
 
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 portable ventilator. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found a home ventilator is not medically 
necessary. This enrollee has severe chronic obstructive pulmonary disease (COPD) with a recent 
hospitalization for acute on chronic hypoxic and hypercarbic respiratory failure. The enrollee benefited from 
bilevel positive airway pressure (bipap) treatment in the hospital, but partial pressure of carbon dioxide 
(PaCO2) did not normalize. This does not constitute failure of bipap by Medicare criteria. The enrollee 
reportedly has bipap at home, but settings and compliance are not provided. There is no documentation of 
bipap failure in the home setting, using average volume-assured pressure support (AVAPS). 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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the BaroStim Neo System implant for the enrollee. 
 
You asked the Plan to pre-approve the implant. You say that this is medically necessary. The Plan denied your 
request. The Plan says further investigation is still underway on the efficacy of this procedure. 
 
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 implant. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found Baroreflex stimulation devices have been considered as potential alternative treatments for resistant 
hypertension and heart failure. The Barostim Neo system is an electronic pulse generator implanted underneath 
the clavicle with a lead tunneled under the skin to the carotid sinus in the neck. The pulse generator delivers 
electrical impulses, analogous to a cardiac pacemaker, to the baroreceptors of one of the carotid arteries. In 
August 2019 the Food and Drug Administration (FDA) approved the system for use in patients with refractory 
heart failure who remain symptomatic despite treatment with guideline-directed medical therapy, are NYHA 
Class III, have an ejection fraction less than 35%, and are not candidates for bi-ventricular pacing. This was 
based on a clinical study demonstrating improvement in normal daily activities, distance walked, quality of life, 
and improved cardiac levels biomarker levels. There remains an absence of randomized, blinded clinical 
studies examining long-term clinical outcomes establishing the value of Barostim Neo in patient management. 
As a result, at this time the Barostim Neo system would not be considered medically reasonable and necessary 
in this patients clinical management. 
 
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 implant have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the BaroStim Neo System implant for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the scaling and root planing (D4342 x 2) and extractions 
(D7140 x 2) provided on June 30, 2021, by the out of network dentist. 
 
You asked the Plan to pay for the dental services. You say that you were unaware that the provider was out of 
network. The Plan denied your request. The Plan says if you choose to see an out of network dentist you might 
be billed for any amount greater than what the plan pays. 
 
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 and the services are listed as covered, 
out of network dentists may bill you for any amount greater than what the plan pays. Therefore, we decided that the Plan does not have to pay for the scaling and root planing (D4342 x 2) and extractions (D7140 x 2) provided on June 30, 2021, by the out of network dentist.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria 
 
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, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional injection services (96375) provided on October 4, 2021. 
 
You asked the Plan to pay for additional injection services. You say that the requested services were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 96375 
is a column II code to column I code 71260. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for additional injection services (96375) provided on October 4, 2021.
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 requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 daily 
skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing 
services. The documentation does not support that it is medically reasonable and necessary to provide skilled 
therapy services on a daily basis. As a practical matter, the enrollee does not require the necessary services on 
an inpatient basis, in a skilled nursing facility 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 skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Iv tubing extension set (S1015) provided on September 
16, 2021. 
 
You asked the Plan to pay for code S1015. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered as billed. 
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 looked at the file and Medicare rules. In this case, CPT code S1015 has a status code of "I" under the 
Medicare Physicians Fee Schedule Database (MPFSDB) and is not valid for Medicare purposes. Medicare uses 
another code for reporting of, and payment for, this service. Therefore, we decided that the Plan does not have 
to pay for the Iv tubing extension set (S1015) provided on September 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation of the sacroiliac joint. 
 
You asked the Plan to pre-approve the services. You say that the state of living with chronic pain should be 
considered and the appeal should be approved. The Plan denied your request. The Plan says radiofrequency 
ablation of the sacroiliac joint is considered investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that this is considered an experimental/investigational approach because of the wide variation in efficacy 
reported in the peer reviewed literature. Therefore, the request is deemed not medically reasonable or 
necessary. 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve radiofrequency ablation of the sacroiliac joint.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for any of the eyewear services provided on June 16, 2021.
You asked the Plan to pay for eyewear. You say that this benefit should be paid. The Plan denied your request.
The Plan says the submitted receipt was insufficient proof of payment. Maximus partially overturned the Plans
denial. The Plan requested a reopen and provided additional information. The Plans stated that the direct
member reimbursement form was submitted for $285. The vision account listed is shared by three persons in
your household. The Claims history shows $387.20 was paid to the retail vision provider but does not corelate
with the itemization receipt from the vision center. Reimbursement cannot be paid without receipts reflecting
the appropriate amount and the appropriate services.
The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all
cost sharing information. The plan contract and the direct member reimbursement forms are clear that
appropriate receipts must be submitted. The charges on the receipts submitted do not match the charges
reported by the vision retailer. Therefore, we decided that the Plan does not have to pay for any of the eyewear
services provided on June 16, 2021.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Amphotericin B 50mg solution for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary to be used in a nebulizer. 
The Plan denied your request. The Plan says that this treatment is not supported by the literature, compendia, or 
guidelines to treat invasive pulmonary aspergillosis. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 drug. Our reviewer says that the 
requested drug is medically reasonable and necessary. Our physician reviewer found treatment with nebulized 
amphotericin B is considered reasonable and necessary for this patient. The patient has invasive aspergillosis 
which has recurred despite response to previous treatment with various antifungal agents. Cresemba had to be 
stopped because of hepatitis. The patient previously tolerated inhaled ampho B. Although this is not a typically 
approved indication for this drug, all other treatments have been considered or tried, and the treatment plan that 
includes long-term inhaled ampho B appears to be the best option for the patient. 
 
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 drug have been met. Therefore, we decided that the Plan has to pre-approve 
Amphotericin B 50mg solution for the enrollee.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the patient meets criteria for LTACH 
services. The Plan denied your request. The Plan says the enrollee does not meet the requirement for an 
LTACH admission. 
 
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 continued to receive acute care services and these had not been denied. 
The medical record does not indicate that the enrollee required services that he was not currently receiving but 
that would be available at the LTACH facility. The elements of the coverage rules are not satisfied, and 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
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. The Plan denied your request. The Plan says 
admission to an LTACH should not take the place of completion of treatment in an acute care hospital. 
 
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 that 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 he 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 Dexcom G6. 
 
You asked the Plan to pre-approve a Dexcom G6. 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. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of a Dexcom G6 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for sinus augmentation (D7952), a tooth extraction (D7210), an 
endosteal implant (D6010), a bone replacement graft (D4263), endodontic therapy (D3330), and a 
prefabricated post and core (D2954) provided by an out-of-network provider on August 8, 2017. 
 
You asked the Plan to pay for sinus augmentation, a tooth extraction, an endosteal implant, a bone replacement 
graft, endodontic therapy, and a prefabricated post and core. You say that you would like the Plan to pay for 
this. The Plan denied your request. The Plan says the rendered dental services are not covered benefits. 
 
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 sinus augmentation (D7952), a tooth extraction (D7210), an endosteal implant (D6010), a bone replacement graft (D4263), endodontic therapy (D3330), and a prefabricated post and core (D2954) provided by an out-of-network provider on August 8, 2017.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the re-cement of crown (D2920) provided on November 30, 2021. 
 
You asked the Plan to pay for dental code D2920. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says per your claim's history, you previously 
received the re-cement crown services on the same tooth on January 12, 2021, and May 6, 2021. You can only 
receive this service once per tooth every 12 months. 
 
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. 
 
We looked at the file, the Plan's contract, and Medicare rules. The file shows that you previously received the 
re-cement crown services on the same tooth on January 12, 2021, and May 6, 2021. The Plan's contract clearly 
shows that you can only receive this service once per tooth every 12 months. Therefore, we decided that the 
Plan does not have to pay for the re-cement of crown (D2920) provided on November 30, 2021.