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

 
We decided that the Plan does not have to pre-approve percutaneous image-guided lumbar decompression 
(PILD or the MILD procedure). 
 
You asked the Plan to pre-approve MILD procedure. You say that this is the only procedure you can get to 
have your pain go away. The Plan denied your request. The Plan says this is not covered because you are not 
enrolled in a required Coverage with Evidence Development (CED) trial for this procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare covers the MILD procedure through 
CED for beneficiaries with lumbar spinal stenosis who are enrolled in an approved clinical study.  
 
We looked at the file and Medicare rules. You are not enrolled in an approved clinical study for this procedure. 
Therefore, you cannot receive coverage for the MILD procedure through CED at this time. Based on this 
information, we decided that Medicare rules for coverage of MILD procedure have not been met. Therefore, 
we decided that the Plan does not have to pre-approve percutaneous image-guided lumbar decompression 
(PILD or the MILD procedure).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve an acute inpatient rehabilitation facility (IRF) admission and 
services. 
 
You asked the Plan to pre-approve these services. You say that the requested services are medically necessary. 
The Plan denied your request. The Plan says that you do not meet medical necessity criteria for coverage of the 
requested services. 
 
The Plan must follow Medicare rules. The rules 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 not provided medical records in this case to support 
their decision. The Plan has not substantiated their denial; therefore, we must find in your favor. Therefore, we 
decided that the Plan has to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.  
 
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 Dexcom G6 therapeutic continuous glucose monitor 
(CGM) transmitter and sensor. 
 
You asked the Plan to pre-approve a Dexcom G6 therapeutic CGM transmitter and sensor. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the enrollee does not meet criteria 
for the requested device. 
 
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. Based on this information, we decided that Medicare rules for coverage of a 
Dexcom G6 therapeutic CGM transmitter and sensor have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Dexcom G6 therapeutic continuous glucose monitor (CGM) transmitter and 
sensor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee will not get the care that they need 
unless admitted to rehabilitation. The Plan denied your request. The Plan says the Medicare guidelines for IRF 
admission were not met and the enrollee can receive the care that they need at a lower level of care like at a 
skilled nursing facility (SNF). 
 
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 enrollee is medically stable and does not need physical medicine and 
rehabilitation physician's close supervision 3 times per week (at a minimum) for the ongoing management of 
any active or acute exacerbations of chronic medical conditions. There are no nursing needs documented. At 
the current functional level, the enrollee does not need 3 hours a day and 5 days a week of therapies with 
multidisciplinary approach in an IRF. 
 
The documentation does not support medical necessity for admission to an IRF. The enrollee has no current 
medical complexity or rehabilitation nursing needs other than routine nursing care. While the enrollee may 
benefit from physical therapy and occupational therapy, the enrollee's rehabilitation needs can be safely met in 
an alternate and low intensity setting such as in a SNF. 
 
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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (PCD) described by 
code E0652 and full leg sleeve from an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve these services. You say that you are the only provider that has this device. 
The Plan denied your request. The Plan says the services are available from network providers. 
 
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. The Plan confirmed that the network 
provider is able to provide an E0652 PCD and full leg sleeve. 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 
pneumatic compression device (PCD) described by code E0652 and full leg sleeve from an out-of-network 
(OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home mechanical ventilator. 
 
You asked the Plan to pre-approve the ventilator. You say that this is medically necessary. The Plan denied 
your request. The Plan says the request for a home mechanical ventilator set in volume-assured pressure 
support (VAPS) mode with auto-EPAP (AE) that could be delivered by bilateral positive airway pressure 
(BiPAP) is not covered. 
 
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 the ventilator. Our reviewer says that 
the requested ventilator is not medically reasonable or necessary. Our physician reviewer found that the 
enrollee has severe obesity and obstructive sleep apnea (OSA) on continuous positive airway pressure (CPAP) 
and was recently hospitalized with pneumonia and gall bladder disease. The record describes repeated admissions with hypercarbic respiratory failure, although there are no arterial blood gas (ABG) results 
provided. COPD is mentioned, but there is no confirmation with pulmonary function tests. There is no 
diagnosis of thoracic restrictive disease or neuromuscular disease. If the patient does have chronic CO2 
retention, may benefit from bilateral positive airway pressure (BiPAP) during sleep. But 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 the ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home mechanical ventilator.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says that the admission to an IRF is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found that the clinical documentation shows complex functional impairments with right hemiparesis. The 
evaluating therapists recommend intense therapy in an IRF setting. The clinical documentation shows that the 
enrollee has multiple active issues and is high risk for multiple complications thus would be expected to require 
continued inpatient hospitalization during rehabilitation. The complexity of the enrollee's nursing, medical and 
rehabilitation needs require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute IRF admission and services.  
 
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 pre-approve computed tomography (CT) scan of the heart with 
quantitative evaluation of coronary calcium. 
 
You asked the Plan to pre-approve CT scan of the heart with quantitative evaluation of coronary calcium. You 
say that this is medically necessary for your condition. The Plan denied your request. The Plan says this is not 
covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that quantitative calcium scoring is not a covered 
service and will be denied as not medically necessary. Based on this information, we decided that Medicare 
rules for coverage of CT scan of the heart with quantitative evaluation of coronary calcium have not been met. 
Therefore, we decided that the Plan does not have to pre-approve computed tomography (CT) scan of the heart 
with quantitative evaluation of coronary calcium.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lift chair. 
 
You asked the Plan to pre-approve a lift chair. You say that the provided records should support the necessity 
of the requested service. The Plan denied your request. The Plan says your provider did not submit the clinical 
information needed to approve the requested lift chair. 
 
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 lift chair have been met. The records 
show that the Plan made multiple attempts to obtain needed clinical information from the provider and the 
requested information was not received. Therefore, we decided that the Plan does not have to pre-approve a lift 
chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve power wheelchair. You say that this is necessary for the enrollee to continue 
living safely at home. The Plan denied your request. The Plan says this provider is out-of-network with the 
Plan and the needed equipment can be provided within the Plan network. 
 
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 power wheelchair to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve full-length bedside rails. 
 
You asked the Plan to pre-approve these services. You say that you have fallen four times last year trying to get 
off of the bed. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that side rails (E0305, E0310) or safety enclosures (E0316) 
are covered when they are required by the beneficiary's condition and they are an integral part of, or an 
accessory to, a covered hospital bed. 
 
We looked at the file and Medicare rules. The file shows that you do not have a covered hospital bed. Based on 
this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, 
we decided that the Plan does not have to pre-approve full-length bedside rails.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional routine transportation trips in 2022. 
 
You asked the Plan to pay for additional transportation. You say that this transportation is necessary for you to 
attend your medical appointments. The Plan denied your request. The Plan says your benefit covers a 
maximum of 60 routine transportation trips per year. Additional trips are not a covered 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 60 trips per year.  
 
We looked at your request, the records in the case file, and the rules. 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 pay for additional routine transportation trips in 2022.
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 at the time of the appeal, IRF admission was medically necessary. 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 criteria.
The Plan is correct in this case. 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. The rules state one of the therapies must be physical therapy or occupational therapy. The patient must actively participate in an intensive rehabilitation therapy program. This intensive rehabilitation therapy program generally consists of at least three hours of therapy per day at least five days per week.
Based on the medical records provided, at the time of the appeal, your physical abilities were not such that this participation would have been possible. 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: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to waive the copayment for a physical therapy visit provided on January 12, 2022.
You asked the Plan to waive the copayment for a physical therapy visit. You say that you did not have physical therapy after your surgery. The Plan denied your request. The Plan says that that you have been charged the correct cost sharing amount.
The Plan must follow Medicare rules. The rules 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. The Plan did not provide medical records to show if a physical therapy visit took place. Without the medical records we are unable to determine if the cost sharing amount applied is correct. Therefore, we decided that the Plan has to waive the copayment for a physical therapy visit provided on January 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the phlebotomy and waive the coinsurance for saline solution infusion provided on March 11, 2022.
You asked the Plan to waive the copayment for the phlebotomy and waive the coinsurance for saline solution infusion. You say that this blood draw happened in the provider's office, and you should not have to pay the 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 $75 copayment for diagnostic procedures and tests and a 20% coinsurance for Medicare Part B drugs.
You have been asked to pay a $75 copayment for the phlebotomy and a 20% coinsurance for the saline solution infusion. This phlebotomy falls within the diagnostic procedures and tests and the saline solution falls within the Medicare Part B drugs 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 the phlebotomy and waive the coinsurance for saline solution infusion provided on March 11, 2022.
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 at the time of the appeal, SNF care was medically necessary. The Plan denied your request. The Plan says Medicare criteria for continued SNF care were not met. Maximus overturned the Plans denial due to a lack of notice of non-coverage in the file. The Plan requested a reopen and provided the required document.
The Plan is correct in this case. 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. Based on the medical records provided, as of September 23, 2021, your care was custodial in nature and the required Medicare coverage criteria for continued care were not met. You were given an appropriate notice of non-coverage on that your covered stay would end on September 25, 2021, which you signed. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the incision and drainage of abscess (D7510) and problem focused limited oral evaluation (D0140) provided on January 12, 2022.
You asked the Plan to pay for the dental services. You say that the abscess was medically necessary, and the oral evaluation had to be completed before you could receive the root canal. The Plan denied your request. The Plan says that the incision and drainage of abscess is not a covered service, and that the frequency limitation has been met for the problem focused limited oral evaluation.
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, certain limitations apply. The record shows your benefit for the problem focused limited oral evaluation was exhausted on date of service December 20, 2021. Though the Plan offers a dental benefit in excess of Medicare coverage, the incision and drainage of abscess is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the incision and drainage of abscess (D7510) and problem focused limited oral evaluation (D0140) provided on January 12, 2022.