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

We decided the Plan does not have to provide coverage a second set of facet joint injections and sedation.
You asked the Plan to provide coverage this request. You say that this treatment is medically necessary for the enrollee. The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue was coverage for a second set of facet joint injections and sedation. The Maximus Physician Reviewer determined that a second set of diagnostic medial branch blocks was necessary and medically reasonable. However, the patient did not have an indication for monitored anesthesia care. Records do not support that this service is medically necessary. The Plan requested a reopen and stated that the Medicare rules were not met.
The medical records show the enrollee had lumbar spondylosis and lumbago. The plan was for bilateral lumbar medial nerve injections at L3/L4 and L4/L5 with sedation. The plan approved 2 units of each injection and denied the remaining 2 units. The plan is correct in this case. LCD L33930 states that a second confirmatory diagnostic facet joint procedure is considered medically reasonable and necessary in patients who meet both of the following criteria: The patient meets the criteria for the first diagnostic procedure, and after the first diagnostic facet joint procedure, there must be a consistent positive response of at least 80% relief of primary (index) pain (with the duration of relief being consistent with the agent used).
As the first diagnostic facet joint procedure had not yet been performed, the coverage criteria had not been met 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 this request have not been met. Therefore, we decided that the Plan does not have to provide coverage a second set of facet joint injections and sedation for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the bone replacement graft for ridge preservation 
(D7953), the guided tissue regeneration (D4266), and the surgical placement of implant body (D6010, D6104) 
to be provided by an out-of-network provider. 
 
You asked the Plan to pre-approve the dental services. You say that your tooth is very painful, and the services 
are covered by your insurance. The Plan denied your request. The Plan says dental services from a non-
assigned provider are not covered by your supplemental benefits. 
 
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. 
 
You are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested items or services are not covered under this benefit when received 
from an out-of-network provider.  Therefore, we decided that the Plan does not have to pre-approve the bone replacement graft for ridge 
preservation (D7953), the guided tissue regeneration (D4266), and the surgical placement of implant body 
(D6010, D6104) to be provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete denture - maxillary (D5110), and complete 
denture - mandibular (D5120). 
 
You asked the Plan to pre-approve the dental services. You say that you really need new dentures. The Plan 
denied your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service January 30, 2020. 
Therefore, we decided that the Plan does not have to pre-approve a complete denture - maxillary (D5110), and 
complete denture - mandibular (D5120).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arthrodesis sacroiliac joint (27280) and associated 
inpatient admission. 
 
You asked the Plan to pre-approve arthrodesis sacroiliac joint and associated inpatient admission. You say that 
the 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 arthrodesis sacroiliac joint and 
associated inpatient admission. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found the enrollee has previous 
lumbar fusion and degenerative back pain without sacroiliac joint instability, fracture, or lesion. Sacroiliac joint 
fusion is experimental for degenerative back pain. 
 
   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of arthrodesis sacroiliac joint and associated inpatient admission have not been 
met. Therefore, we decided that the Plan does not have to pre-approve arthrodesis sacroiliac joint (27280) and 
associated inpatient admission.
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 therapeutic CGM. You say that this device is medically necessary for your 
condition. The Plan denied your request. The Plan says the criteria for coverage have not been met for this 
device. 
 
The Plan must follow Medicare rules. 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 a therapeutic CGM have been met. In 
this case, the Plan sent several requests to your provider for medical records to support the requested CGM. No 
medical records supporting the device were returned to indicate the criteria for coverage have been met. 
Therefore, we decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor 
(CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies 
(K0553, K0554). 
 
You asked the Plan to pre-approve a CGM and supplies. You say that your diabetes type 2 mellitus 
w/hyperglycemia is out of control even after taking several medications. The Plan denied your request. The 
Plan says you do not meet the coverage criteria for the requested CGM and supplies. 
 
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 the enrollee does not use insulin 
with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a CGM and 
supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor (CGM) and supplies (K0553, K0554).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown - porcelain tooth #'s 7, 8, 9, 10, 11, 12, 13, and 
20 (D2750), and core buildup, including any pins when required (D2950) for tooth #'s 7, 8, 9, 10, 11, 12, 13, 
and 20. 
 
You asked the Plan to pre-approve the crown - porcelain tooth #'s 7, 8, 9, 10, 11, 12, 13, and 20 (D2750), and 
core buildup, including any pins when required (D2950) for tooth #'s 7, 8, 9, 10, 11, 12, 13, and 20. You say 
that the services are medically necessary. The Plan denied your request. The Plan says there is no clinical 
evidence to support medical necessity. 
 
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 the crown - 
porcelain tooth #'s 7, 8, 9, 10, 11, 12, 13, and 20 (D2750), and core buildup, including any pins when required 
(D2950) for tooth #'s 7, 8, 9, 10, 11, 12, 13, and 20 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 the crown - porcelain tooth #'s 7, 8, 9, 
10, 11, 12, 13, and 20 (D2750), and core buildup, including any pins when required (D2950) for tooth #'s 7, 8, 
9, 10, 11, 12, 13, and 20. Our reviewer says that based on the provided documentation, tooth #'s 7, 8, 9, 10, 11, 
12, 13, and 20 show minimal structural damage with some small existing restorations and no clear need for full 
coverage restorations as requested. Our physician reviewer found the amount of remaining structure in this case 
would not support the need for a metal or ceramic crown. The core buildups would also not be necessary as 
they are foundation restorations needed only when a crown could not be retained without it. As none of the 
teeth in question have significant breakdown, neither the core buildup or crowns would be considered 
necessary. 
 
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 the crown - porcelain tooth #'s 7, 8, 9, 10, 11, 12, 13, and 20 (D2750), and core 
buildup, including any pins when required (D2950) for tooth #'s 7, 8, 9, 10, 11, 12, 13, and 20 have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a crown - porcelain tooth #'s 7, 8, 9, 10, 
11, 12, 13, and 20 (D2750), and core buildup, including any pins when required (D2950) for tooth #'s 7, 8, 9, 
10, 11, 12, 13, and 20.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive exam provided on July 7, 2022. 
 
You asked the Plan to pay for the dental service. You say that you are appealing this claim. The Plan denied 
your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service December 7, 2021. 
Therefore, we decided that the Plan does not have to pay for the comprehensive exam provided on July 7, 
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. The Plan denied your request. The Plan says that the coverage 
criteria has not been 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 that the documentation does not support medical necessity for admission to an IRF. 
You have no medical complexity, and no rehabilitation nursing needs other than routine nursing care. 
While you may benefit from physical therapy and/or occupational therapy, your rehabilitation needs can be safely met in an alternate and low intensity setting such as in a skilled nursing facility. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs (A9270) provided from  
August 11, 2022, through August 12, 2022. 
 
You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says these items are not a covered benefit. 
 
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 provided are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
(A9270) provided from August 11, 2022, through August 12, 2022.  
 Benefits for these items 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76700 billed for date of service July 14, 
2022. 
 
You asked the Plan to pay for procedure code 76700. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76700 is bundled into payment for 
code 93976. 
 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 76700 
is a column II code to column I code 93976. 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 procedure code 76700 billed for date of service July 14, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery services provided on 
March 9, 2022. 
 
You asked the Plan to waive the copayment for outpatient surgery services. You say that you are disputing the 
share cost. 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 $200 
copayment for outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay $200 copayment for outpatient surgery services. This item/service falls within the 
outpatient diagnostic tests and therapeutic services and supplies 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 outpatient surgery services provided on March 9, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a targeted genomic sequence panel (81455) provided on January 3, 2022.
You asked the Plan to pay for this testing. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare coverage criteria are 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 the records are clear that the Medicare coverage criteria for this testing were not met.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare has specific coverage criteria for this type of testing. Based on the medical records provided, the request for a panel of 51 or greater genes is not reasonable or medically necessary according to the coverage criteria established in the LCD.
Medicare rules for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for a targeted genomic sequence panel (81455) provided on January 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the requested device. The Plan denied your request. The Plan says the 
criteria have 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 does not indicate that the enrollee uses insulin 
with at least three daily injections or requires frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of the requested 
device have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on July 25, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the enrollee must receive care from a network provider. 
 
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 laboratory services provided on July 25, 2022, by 
an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for a positron emission tomography (PET) scan. 
 
You asked the Plan to pay for a positron emission tomography (PET) scan. You say that you would like to 
request reconsideration of the denied authorization. The Plan denied your request. The Plan says that the 
member doesn't meet the requirements for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for a positron emission tomography (PET) scan. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found this patient has 
been categorized as having high risk prostate cancer and meets the criteria for 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 positron emission tomography (PET) scan have been met. Therefore, we 
decided that the Plan has to pay for a positron emission tomography (PET) scan.  
 
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: 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 therapeutic CGM. You say that the enrollee is not always able to check 
glucose in a timely manner. The Plan denied your request. The Plan says the enrollee does not meet Medicare 
criteria for a continuous glucose monitor (CGM). 
 
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 the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of therapeutic CGM have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM).