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

 
We decided that the Plan does not have to pre-approve thyroid surgery to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the thyroid surgery. You say that the services should be covered as you 
disagree with the denial and the providers in-network are unqualified to provide these services. The Plan denied 
your request. The Plan says the services denied correctly as they are non-emergent and the same care can be 
provided in-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 
thyroid surgery 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 a power wheelchair and accessories to be provided by 
an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that this is medically 
necessary. The Plan denied your request. The Plan says this is available in-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 and accessories 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 ensure nutritional supplementation. 
 
You asked the Plan to pre-approve ensure nutritional supplementation. You say that you lost a lot of weight and 
cannot afford to pay for this out of pocket. The Plan denied your request. The Plan says the requested items are 
not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that enteral nutrition is covered for a beneficiary who 
requires feedings via an enteral access device.  
 
We looked at the file and Medicare rules. Review of the file shows that the the requested enteral supplies is not 
for use via an enteral access device. Based on this information, we decided that Medicare rules for coverage of 
ensure nutritional supplementation have not been met. Therefore, we decided that the Plan does not have to 
pre-approve ensure nutritional supplementation.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve 17 additional fractions of intensity-modulated radiation therapy 
(IMRT). 
 
You asked the Plan to pre-approve IMRT. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says that the denial of authorization for this service is correct, because 28 
fractions of IMRT have been approved and the record does not show that the enrollee cannot be safely treated 
with these 28 fractions. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 pre-approve IMRT. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found 45 fractions of IMRT is considered acceptable by National Comprehensive Cancer Network 
(NCCN) guidelines and other evidence-based guidelines with acknowledgment of some limitations in the data. 
The requested treatment plan would be furnished in accordance with the accepted standards of medical 
practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IMRT have been met. Therefore, we decided that the Plan has to pre-approve 
17 additional fractions of intensity-modulated radiation therapy (IMRT).  
 
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 Freestyle Libre continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a Freestyle Libre CGM. You say that this is medically necessary. The Plan 
denied your request. The Plan says the submitted records do not show the requirements for coverage have 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 perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and 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 assesses 
adherence to their CGM regimen and diabetes treatment plan. 
 
We looked at the file and Medicare rules. The submitted records do not document that the enrollee performs blood glucose testing at least four times per day, uses insulin with at least three daily injections, and 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 a Freestyle Libre CGM have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor 
(CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a carotid sinus baroreflex activation device for the 
enrollee. 
 
You asked the Plan to pre-approve the device. You say that the enrollee is an ideal candidate for this request. 
The Plan denied your request. The Plan says this is experimental and 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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that at issue is whether the requested authorization for implantation of a Barostim Neo system is 
medically necessary. Baroreflex stimulation devices have been considered 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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a carotid sinus baroreflex activation device for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan has to pre-approve four additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve the four additional PT visits. You say that additional physical therapy visits 
are medically necessary. The Plan denied your request. The Plan says that the four additional physical therapy 
visits are not medically necessary and are considered maintenance now. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 PT visits. Our reviewer says that four 
additional physical therapy sessions are medically necessary. Our physician reviewer found that clinical 
documentation shows the enrollee has severe spasticity and continues to require the skill of a professional 
therapist to continue assessment and treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PT visits have been met. Therefore, we decided that the Plan has to pre-approve 
four additional physical therapy (PT) visits.  
 
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 the MyoPro 2 Motion G orthotic device (L8702). 
 
You asked the Plan to pre-approve the orthotic device. You say that the enrollee has been referred by her 
family practice physician for myoelectric orthotic restoration using the MyoPro Motion G. The Plan denied 
your request. The Plan says this item is considered experimental and investigational. There is insufficient 
evidence of its effectiveness in those with stroke and hemiparesis. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the orthotic device have not been met. Therefore, we decided that the Plan does not have to pre-
approve the MyoPro 2 Motion G orthotic device (L8702).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous process 
stabilization/distraction device, without open decompression or fusion, including image guidance when 
performed, lumbar, single level (22869) insertion of interlaminar/interspinous process stabilization/distraction 
device, without open decompression or fusion, including image guidance when performed, lumbar; second 
level (22870). 
 
You asked the Plan to pre-approve the Vertiflex Superion Interspinous Spacer device. You say that the enrollee 
will particularly benefit from the less invasive approach offered by the Superion Indirect Decompression 
System device as compared to a more invasive laminectomy or spinal fusion procedure. The Plan denied your 
request. The Plan says There are not enough studies to show that use of the interspinous decompression device 
will help in the enrollee's care. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered.  
 We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Vertiflex Superion Interspinous Spacer device have not been met. Therefore, we decided that 
the Plan does not have to pre-approve insertion of interlaminar/interspinous process stabilization/distraction 
device, without open decompression or fusion, including image guidance when performed, lumbar, single level 
(22869) insertion of interlaminar/interspinous process stabilization/distraction device, without open 
decompression or fusion, including image guidance when performed, lumbar; second level (22870).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Medtronics Guardian 3 Sensor. 
 
You asked the Plan to pre-approve a Medtronics Guardian 3 Sensor. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that CGM devices that do not meet the definition of a 
therapeutic CGM as defined in CMS Ruling 1682R will be denied as non-covered (no benefit).   
 
 
 
 
 
 
 
 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a Medtronics Guardian 3 Sensor have not been met. Specifically, the requested item is identified 
with code A9276 (Sensor; invasive (e.g., subcutaneous), disposable, for use with interstitial continuous glucose 
monitoring system, one unit = 1 day supply). This code has a status indicator of N, which means this code is 
a non-covered service. Therefore, we decided that the Plan does not have to pre-approve a Medtronics 
Guardian 3 Sensor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a core buildup, including any pins when required 
(D2950). 
 
You asked the Plan to pre-approve a core buildup. You say that you disagree with the denial and are requesting 
reconsideration for the denied service. The Plan denied your request. The Plan says the service requested is not 
covered. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
core buildup, including any pins when required (D2950).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S0020 billed for date of service February 25, 2021. 
 
You asked the Plan to pay for procedure code S0020. The Plan denied your request. The Plan says the billed 
code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S0020 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S0020 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S0020 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S0020 billed for date of service February 25, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Retacrit. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has high risk 
myelodysplastic syndrome. The Food and Drug Administration (FDA) has not stated that the requested drug is 
indicated for the enrollee's condition. The Medicare approved  drug compendia do not contain a supportive 
citation for the use of the requested drug in the enrollee's clinical situation. Retacrit is therefore not reasonable 
or medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Retacrit.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive or reduce the cost share.
You asked the Plan to waive or reduce this cost share. You say that you do not believe this cost share is correct. The Plan denied your request. The Plan says this cost share was charged based on the claim submitted by the provider and the Plan contract agreement. Maximus partially overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct contract language or Medicare billing guidelines. The Plan demonstrated that the billing guidelines used by Maximus do not apply. The Plan demonstrated that the Medicare guidelines show chemical supplies provided by facilities during the course of treatment can be charged separately and can also incur a cost share.
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 $100 copayment for a PET scan and 20% coinsurance for Medicare Part B drugs. 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 or reduce the cost share charged for a cardiac positron emission tomography (PET) scan and Part B drug, Regadenoson, provided on November 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve furniture for use with a seat lift mechanism. 
 
You asked the Plan to pre-approve furniture for use with a seat lift mechanism. You say that you disagree with 
the Plan's denial. The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that seat lift chairs are not covered. Coverage is limited to 
a seat lift mechanism. 
 
 
 We looked at the file and Medicare rules. The request is for the chair/seat part for a seat lift mechanism. 
Although a seat lift chair may be appropriate, Medicare does not cover this item and the Plan must provide 
coverage only for items that Medicare covers. Therefore, we decided that the Plan does not have to pre-approve 
furniture for use with a seat lift mechanism.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that an epidural steroid injection is 
medically necessary. The Plan denied your request. The Plan says an epidural steroid injection is not medically 
necessary. 
 
The Plan follows Medicare rules.  
 
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 an epidural steroid injection. Our 
reviewer says that an epidural steroid injection is not medically necessary. Our physician reviewer found that 
the LCD criteria requires that the pain relief exceeds 50% for 3 months to be deemed effective. This was not 
met and therefore, the request is deemed not medically reasonable and 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 an epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 12001 billed for date of service August 26, 2021. 
 
You asked the Plan to pay for procedure code 12001. You say that the appropriate level of service was applied 
based on the guidelines which is supported in the provider's documentation. You say that the claim should be 
reprocessed appropriately. The Plan denied your request. The Plan says procedure codes 99285 and 25622 have 
been overturned. The Plan also says payment for code 12001 is bundled into payment for code 25622. 
 
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 12001 
is a column II code to column I code 25622. 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 12001 billed for date of service August 26, 2021.