Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) admission. 
 
You asked the Plan to pre-approve the LTACH admission. You say that the enrollee is too medically complex 
for a lower level of care. You say that an LTACH placement would be beneficial for the enrollee's progress and 
recovery. You also say that the enrollee needs daily physician oversight, 24 hour nursing and respiratory care, 
wound care, telemetry and administration of intravenous (IV) medications. The Plan denied your request. The 
Plan says the LTACH admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH admission. Our reviewer 
says that the requested LTACH admission is not considered medically reasonable and necessary in this case. 
Our physician reviewer found the provided documentation does not indicate medical necessity for admission to 
a LTACH. The reviewer found that the documentation indicates the enrollee is receiving appropriate care at the 
present acute care hospital. The documentation indicates the enrollee does not require services at the LTACH 
that are not available at the acute care hospital where they are currently receiving care. There are no services 
available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. Therefore, the reviewer found that the requested LTACH services are not medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH admission have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) admission.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam radiation therapy for the enrollee. 
 You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that this is not covered by the Plan. 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve these services as part of a clinical trial. The Plan does not cover 
routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-
approve proton beam radiation therapy for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a new walker with seat.
You asked the Plan to provide coverage for this equipment. You say that a new walker with seat is medically
necessary. The Plan denied your request. The Plan says you were provided a walker in April of 2020 and this
item is not eligible for replacement. Maximus overturned the Plans denial as there was no documentation of the
walker provided in 2020. The Plan requested a reopen and submitted the required information.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare replaces durable medical
equipment every five years unless it cannot be repaired, or cost or repair is greater than replacement. There
are no records or durable medical provider evaluations to show your current walker either needs repair or
cannot be repaired. There is no documentation to show the walker you have currently does not you're your
needs in the home. Medicare does not cover equipment for use outside of the home. Therefore, we decided that
the Plan does not have to provide coverage for a new walker with seat.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve PT.  
 
You asked the Plan to pre-approve PT. You say that physical therapy is medically necessary. The Plan denied 
your request. The Plan says physical therapy is not medically necessary. 
 
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. Our reviewer says that skilled 
services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. 
Our physician reviewer found that clinical documentation does not show clear therapy goals and the enrollee is 
currently using a home exercise plan.  
 
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 have not been met. Therefore, we decided that the Plan does not have to pre-
approve physical therapy (PT).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service November 2, 
2021. 
 
You asked the Plan to pay for procedure code 70450. You say that you would like this code reprocessed and 
approved for payment. The Plan denied your request. The Plan says payment for code 70450 is bundled into 
payment for code 70496. 
 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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service November 2, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided the Plan does not have to waive the copayment charged for dental series provided on May 20, 2021.
You asked the Plan to waive this copayment. You say that you were told dental services were covered at 100%.
The Plan denied your request. The Plan says that the schedule of benefits states that there is a $20 copayment
for a root canal (D3310) and a $295 copayment for a root canal retreatment (D3346). The Plan says this claim
was processed correctly. Maximus overturned the Plans denial for insufficient contract information to confirm
this copayment. The Plan requested a reopen and provided the required contract information.
The Plan is correct in this case. Medicare does not cover dental services. The Plan offers a dental benefit that
exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plans dental
contract states each of these services has a cost share. The Plan contract says that there is a $20 copayment for
code D3320 and a $295 copayment for code D3346.
This cost share is your contractual obligation. Therefore, we decided that the Plan does not have to waive the
copayment charged for dental series provided on May 20, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Stabilink MIS interlaminar spinal fixation system. 
 
You asked the Plan to pre-approve Stabilink MIS interlaminar spinal fixation system. You say that the services 
are necessary. The Plan denied your request. The Plan says medical necessity has not been established. 
Therefore, coverage criteria have not been met. 
 
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 Stabilink MIS interlaminar spinal 
fixation system. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found Stabilink interlaminar fusion device is experimental. 
More research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Stabilink MIS interlaminar spinal fixation system have not been met. Therefore, 
we decided that the Plan does not have to pre-approve Stabilink MIS interlaminar spinal fixation system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office services to be performed by an out-of-
network provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that continuing with the same provider 
will be most beneficial. The Plan denied your request. The Plan says there are in-network providers that can 
render the services. 
 
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 
the office services to be performed by an out-of-network provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an EGD and endoscopy upper GI. 
 
You asked the Plan to pre-approve an EGD and endoscopy upper GI. You say that an EGD and endoscopy 
upper GI are medically necessary. The Plan denied your request. The Plan says an EGD and endoscopy upper 
GI are not medically necessary based on the Medicare LCD. 
 
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 EGD and endoscopy upper GI. Our 
reviewer says that an EGD and endoscopy upper GI are not medically necessary. Our physician reviewer found 
that the record indicates that the enrollee has had weight loss. The record provided is insufficient to establish 
that the coverage criteria of the requested service are satisfied. The elements of the coverage criteria are not 
satisfied. The requested service is not recommended.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an EGD and endoscopy upper GI have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an EGD and endoscopy upper GI.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services coded A4550, 99156, and 99157 
provided on December 23, 2020. 
 
You asked the Plan to pay for the medical services as billed. You say that you would like these codes 
reprocessed and approved for payment. The Plan denied your request. The Plan says these codes have denied 
correctly based on Medicare coding regulations. 
 
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 codes 99156 and 99157 are both column II codes to column I code 64493 
with a modifier indicator of 0. The column II codes are therefore not payable. In addition, we find that CPT 
code A4550 has a status indicator of B on the Physician Fee Schedule. This means that CPT code A4550 is not 
separately payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the medical services coded A4550, 99156, and 99157 provided 
on December 23, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex (22869, 22870). 
 
You asked the Plan to pre-approve the Vertiflex device. You say that included with this letter is the clinical 
documentation which supports these clinical finds and medical necessity for the procedure. The Plan denied 
your request. The Plan says this device is unproven and experimental and is not covered. More studies are 
needed to show Vertiflex is safe and effective. 
 
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 Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-
approve the Vertiflex (22869, 22870).
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 meets the full criteria for an inpatient 
acute rehabilitation stay in a hospital setting that can provide adequate supervision as therapies are advanced. 
The Plan denied your request. The Plan says according to the available records, the enrollee appears near the 
preadmission baseline. The enrollee does not have acutely complex medical diagnosis and does not require 
supervision by a rehabilitation physician. The enrollee does not meet all the required Medicare criteria for 
admission to an IRF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee was admitted for weakness, diarrhea, and hyperkalemia after missing 
dialysis. Medical problems are stable. there are no complex nursing or rehabilitation needs. While the enrollee 
has a need for physical or occupational therapy, there is no documentation of a need for an intensive 
rehabilitation program. 
 
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 an occlusal guard-hard appliance, full arch (code 
D9944). 
 
You asked the Plan to pre-approve the occlusal guard. You say that you grind your teeth and need this device to 
prevent further damage. The Plan denied your request. The Plan says this is not a covered service under your 
plan. 
 
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 an 
occlusal guard-hard appliance, full arch (code D9944).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple power 
options and attachments for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that this request exceeds the patient's needs. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The patient has a 
mobility deficit that impairs MRADLs in the home. The patient cannot use a manual wheelchair due to bilateral 
upper and lower extremity ataxia, decreased coordination and right lower extremity weakness. The patient 
cannot use a cane or walker as he is non-ambulatory with impaired balance. The documentation does not reveal 
that the patient uses a ventilator attached to a wheelchair, is at high risk for development of a pressure ulcer. There is no evidence of intermittent catheterization. The physician documentation does not indicate objective 
evidence of spasticity on a bilateral lower extremity physical exam that the enrollee needs a power seating 
system for management therefore the request for power recline exceeds the patient's medical needs. A 6/28/22 
wheelchair evaluation states the patient is also noted to have impaired overall cognitive status. He follows one 
step commands with repetition and has decreased awareness of the need for assistance. The documentation 
does not fully support that the patient can safely operate this device given his decreased safety awareness and 
cognition. Additionally, the request for tilt and recline exceeds the patient's medical needs. The request for a 
Group 3 power wheelchair with multiple accessories exceed the patient's medical need. Our physician reviewer 
found that the enrollee's condition does not meet Medicare criteria for these services. 
 
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 a Group 3 power wheelchair with multiple power options and attachments for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prefabricated abutments for tooth #5, 20, 29, and 30 
(D6056), and implant supported porcelain/ceramic crowns for tooth #5, 20, 29, and 30 (D6065). 
 
You asked the Plan to pre-approve abutments and implant supported crowns. You say that you started implant 
placement last year with your dentist, and you wish to complete the treatment. You say you need the crowns to 
eat food properly. The Plan denied your request. The Plan says the services requested are not covered under 
your supplemental dental 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. 
 
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 
prefabricated abutments for tooth #5, 20, 29, and 30 (D6056), and implant supported porcelain/ceramic crowns 
for tooth #5, 20, 29, and 30 (D6065).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of lateral exostosis (D7471) provided by a 
participating provider. 
 
You asked the Plan to pre-approve dental services. You say that these services are medically necessary for you. 
The Plan denied your request. The Plan says the requested dental services are not a covered benefit. 
 
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 the 
removal of lateral exostosis (D7471) provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endosteal implants on tooth #22 and 27 (D6010), 
precision attachment on tooth #22 and 27 (D5862), and implant supported removable denture (D6111). 
 
You asked the Plan to pre-approve the dental services. You say that you disagree with the denial of dental 
services. The Plan denied your request. The Plan says endosteal implants (D6010), precision attachment 
(D5862), and implant supported removable denture (D6111) are not covered by your routine dental 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. 
 
 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 
endosteal implants on tooth #22 and 27 (D6010), precision attachment on tooth #22 and 27 (D5862), and 
implant supported removable denture (D6111).