Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oral appliance (code E0486). 
 You asked the Plan to pre-approve oral appliance. You say that the enrollee's diagnosis more than qualifies for 
coverage. The Plan denied your request. The Plan says the denial of authorization for this device is correct, 
because the enrollee does not meet criteria. 
 
The Plan follows Medicare rules. Medicare rules state that a custom fabricated mandibular advancement oral 
appliance may be covered if certain 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 oral appliance. Our reviewer says that 
the enrollee does not meet the Medicare criteria for the requested oral appliance. Our physician reviewer found 
a continuous positive airway pressure (CPAP) appears to be effective for the enrollee, and no dentist has been 
consulted for an evaluation to determine the practicality of an oral appliance to treat the enrollee's condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of oral appliance have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an oral appliance (code E0486).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on November 1, 2021. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you were 
told that ambulance service is covered as long as there is transportation. You also say that this is not stated in 
the plan guide and that the services that you received appear to be an exception to the benefit listed. The Plan 
denied your request. The Plan says the ambulance was called, and you were not transported to an emergency 
facility. The Medicare ambulance benefit is a transport benefit. The Plan also says that if no transport of a 
Medicare beneficiary occurs, then there is no Medicare covered services. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on November 1, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport (A0998) provided on November 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to waive the copayment for a specialist office visit provided on August 4,
2021.
You asked the Plan to waive this copayment. You say that you do not believe this cost share is correct because
you only saw the nurse and not the doctor. The Plan denied your request. The Plan says this cost share was
charged based on the services provided and the Plan contract agreement. Maximus partially overturned the
Plans denial for insufficient claim information in the case file. The Plan requested a reopen and showed
documentation of this claim being billed as a specialist visit.
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 (such as copayments, deductibles and coinsurance).
Your contract with the Plan clearly says that there is a $50 copayment for each specialist or any other physician
or other health care professional visit for Medicare-covered benefits in a specialist setting. This means
that when you go to a specialist's office, you may or may not see a physician, but any professional staff
providing a service in this setting qualifies as a specialist office visit. 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 a
specialist office visit provided on August 4, 2021
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endovenous ablation therapy of incompetent vein. 
 
You asked the Plan to pre-approve endovenous ablation therapy of incompetent vein. The Plan denied your 
request. The Plan says the documentation does not show the member had three months of conservative therapy, 
pain or burning that interferes with mobility, episodes superficial phlebitis, varicose bleeding, pruritic skin 
hyperpigmentation, or chronic persistent edema. 
 
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 endovenous ablation therapy of 
incompetent vein. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found the documentation does not meet guideline criteria for 
use of this therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of endovenous ablation therapy of incompetent vein have not been met. Therefore, 
we decided that the Plan does not have to pre-approve endovenous ablation therapy of incompetent vein.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that you would like the Plan to reconsider 
their denial. The Plan denied your request. The Plan says incontinence supplies are not covered by Medicare or 
the Plan. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee will clearly benefit from IRF to optimize 
level of function before returning home. The Plan denied your request. The Plan says the denial of 
authorization for IRF care is correct. 
 
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 complexity of the enrollee's nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
enrollee may need physical and/or occupational therapy, there is no documented need for 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the bone graft (21215), reconstruction of mandible 
(22148) and dental procedures (41899). 
 
You asked the Plan to pre-approve the dental services. You say that the services are medically necessary. The 
Plan denied your request. The Plan says the requested surgical extraction of teeth, bone graft, and dental 
implants, even though they are solely for the purpose of replacing teeth following loss of teeth due to 
treatment of the member's ENT cancer, does not meet any of the very narrow reasons that Medicare covers any 
dental care. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement 
of the enrollees teeth or the structures directly supporting the enrollees teeth. These are dental services that 
are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve the 
bone graft (21215), reconstruction of mandible (22148) and dental procedures (41899).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve routine foot care visits. 
 
You asked the Plan to pre-approve routine foot care visits.. You say that you have circulation issues with 
reduced sensation on both feet with a fungal infection on your nails. The Plan denied your request. The Plan 
says routine foot care is not covered unless certain criteria are met. 
 
The Plan must follow Medicare rules. The rules say that routine foot care is not a covered Medicare benefit 
unless you have diabetic foot disease or some other condition that makes professional care of your feet 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Part C Plan was correct in denying the request to pre-approve routine foot care visits. Our 
reviewer says that you do not meet the coverage criteria for routine foot care. Our physician reviewer found 
that routine foot care and care of onychomycosis is covered if the patient demonstrates clinical onychomycosis 
and has a secondary condition including pain, in growing toenails, or limitations in ambulation due to the 
onychomycosis. The clinical notes do not advise that you are suffering with pain, in growing toenails, or 
limitations of ambulation due to their onychomycosis. The medical progress notes advise that this patient does 
not demonstrate insensate areas to either foot. Therefore, we decided that the Plan does not have to pre-approve 
routine foot care visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a KardiaMobile EKG device. 
 
You asked the Plan to pre-approve a KardiaMobile EKG device. You say that the item is medically necessary. 
The Plan denied your request. The Plan says this item does not primarily serve/treat a medical purpose and is a 
convenience item. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a KardiaMobile EKG device.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eylea. 
 
You asked the Plan to pre-approve Eylea. You say that the enrollee had persistent disease activity while being 
treated with Lucentis. The Plan denied your request. The Plan says the enrollee has not tried and failed the 
preferred product. 
 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 Eylea. Our physician reviewer found 
that the record indicates the enrollee has Exudative age-related macular degeneration, right eye, with active 
choroidal neovascularization. The requested medication is a new start. The Plan requires a trial of Avastin 
before they will approve the requested drug. The provided records do not indicate that the enrollee has tried and 
failed the plan's preferred step one alternative. The record does not indicate that the enrollee has a 
contraindication to or would have an adverse effect from the plan's preferred step one alternative. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Eylea have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Eylea.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) (K0554) and 
supplies (K0553). 
 
You asked the Plan to pre-approve a CGM and supplies. You say that the items are medically necessary. The 
Plan denied your request. The Plan says the records indicate that the member does not take insulin at least three 
times per day, does not adjust their insulin doses frequently based on blood sugar readings, and does not use an 
insulin pump. 
 
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 and 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) (K0554) and supplies (K0553).
Appeal type: Surgery
Decision: Unfavorable

We decided the Plan does not have to pay for these services under the Medicare Benefit.
You asked the Plan to waive the cost of these services. You say that you do not believe this cost share is
correct. The Plan denied your request. The Plan says these services must be addressed under your Medicaid
benefit. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional
information. The Plan says that this claim denied under your Medicare benefit because you are Medicaid
eligible. The Plan included documentation to show that you are Medicaid eligible. The Plan says that Medicare
pays covered dually eligible beneficiaries' medical services first, because Medicaid is generally the payer of
last resort. Medicaid may cover medical costs that Medicare may not cover or partially covers (such as nursing
home care, personal care, and home- and community-based services). These services qualified under the
Medicaid coverage.
The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all
cost sharing and coverage information. Your contract states dual eligible enrollees will have services that are
covered by either Medicare or Medicaid, but not by both. The services provided fall under your Medicaid
coverage and not your Medicare coverage. The IRE does not have jurisdiction over your Medicaid benefits.
Therefore, we decided that the Plan does not have to waive the cost share charged for surgical services
provided on April 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the special anesthesia service (99100) provided on August 
25, 2021. 
 
You asked the Plan to pay for the special anesthesia service (99100). You say that the patient needed the 
anesthesia for this procedure. The Plan denied your request. The Plan says procedure code 01936 has been 
overturned. The Plan also says that procedure code 99100 remains denied as bundled services are not eligible 
for separate payment.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99100 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the special anesthesia service (99100) have not been met. Therefore, we decided that the Plan does not have 
to pay for the special anesthesia service (99100) provided on August 25, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gelsyn-3. 
 
You asked the Plan to pre-approve Gelsyn-3. The Plan denied your request. The Plan says the enrollee has not 
tried and failed Orthovisc or Supartz FX. 
 
 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 Gelsyn-3. Our physician reviewer 
found that the record indicates the enrollee has osteoarthritis of the knees. The requested medication is a new 
start. The Plan requires a trial of Orthovisc or Supartz FX before they will approve the requested drug. The 
provided records do not indicate that the enrollee has tried and failed the plan's preferred step one alternative. 
The record does not indicate that the enrollee has a contraindication to or would have an adverse effect from 
the plan's preferred step one alternative. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gelsyn-3 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gelsyn-3.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supplies for maintenance of non-insulin drug infusion 
catheter (A4221), infusion pump with supplies (A4222), and milrinone lactate injection (J2260) provided from 
October 21, 2021, to October 28, 2021. 
 
 
 
 You asked the Plan to pay for the infusion services. You say that the enrollee was not enrolled in hospice on 
the dates of service in this case. The Plan denied your request. The Plan says the enrollees claim would be 
covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of 
election until the last day of the month in which hospice is revoked. The Plan also says it is the providers 
responsibility to verify the enrollees coverage before rendering services and to know proper billing procedures 
for a Medicare Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on October 4, 2021. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the supplies for 
maintenance of non-insulin drug infusion catheter (A4221), infusion pump with supplies (A4222), and 
milrinone lactate injection (J2260) provided from October 21, 2021, to October 28, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care services provided from September 8, 
2021, to September 15, 2021. 
 
You asked the Plan to pay for the home health care services. You say that this claim denied as a duplicate 
service, and these services are not a duplicate. You also say that you would like this claim to be reprocessed. 
The Plan denied your request. The Plan says the RAP claim for these dates of service was not submitted until 
October 18, 2021. 
 
The Plan must follow Medicare rules. Medicare rules say that all Home Health Agencies (HHAs) must submit 
a request for anticipated payment (RAP) within 5 calendar days after the start of care date for initial 30-day 
periods and within 5 calendar days after the from date for each subsequent 30-day period of care, which is set 
at 0 percent at the beginning of every 30-day period.  
 
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health care services have not been met. Specifically, the record indicates the RAP was 
not submitted within 5 days of the from the start of care date, September 15, 2021. Therefore, we decided that 
the Plan does not have to pay for the home health care services provided from September 8, 2021, to September 
15, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee requires 24-hour supervision and her 
spouse is not able to provide the necessary care services. The Plan denied your request. The Plan says the 
criteria for admission to an SNF are not met. The enrollee does not require daily skilled therapy or daily skilled 
nursing care. 
 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 that the enrollee does not have any identifiable 
skilled nursing services needs that would require the specialized skill, knowledge, and judgement of a skilled 
professional nurse to safely and effectively provide medically necessary and reasonable treatment. The enrollee 
does not have identifiable skilled nursing service needs that would require the specialized skill, knowledge and 
judgment of a qualified therapist. The enrollee does not meet severity of illness or intensity of service criteria 
for 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) services.