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

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) 
(K0554, K0553). 
 
You asked the Plan to pre-approve a Freestyle Libre CGM. You say that you need this because your previous 
machine was recalled. The Plan denied your request. The Plan says the requirements for coverage have not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who 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 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 
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) (K0554, K0553)
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lightweight manual wheelchair.
You asked the Plan to pay for the lightweight manual wheelchair. You say that the enrollee needs another wheelchair because he cannot transfer in the other one. The Plan denied your request. The Plan says this service is not covered under Medicare.
The Plan must follow Medicare rules. Medicare rules say payment is made for only one wheelchair at a time. Medicare says that back up chairs are denied as not reasonable and necessary. The base manual wheelchair request is upheld therefore all other add-on components requested to be added to this mobility device are also not covered at this time. Therefore, we decided that the Plan does not have to pay for a lightweight manual wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator, InogenOne G4 (E1392).
You asked the Plan to pre-approve InogenOne G4. You say that your current device no longer meets your needs. The Plan denied your request. The Plan says your current device meets your medical needs.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The file shows that you have an InogenOne G3. This device serves the same purpose as an InogenOne G4. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator, InogenOne G4 (E1392).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transcatheter occlusion or embolization for tumor destruction (S2095).
You asked the Plan to pre-approve transcatheter occlusion or embolization for tumor destruction. You say that the services are necessary. The Plan denied your request. The Plan says code S2095 has a status indicator of "I", which indicates that this service is not valid for Medicare purposes. Therefore, coverage criteria have not been met.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of transcatheter occlusion or embolization for tumor destruction have not been met. Therefore, we decided that the Plan does not have to pre-approve transcatheter occlusion or embolization for tumor destruction (S2095).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the custom fabricated abutment (D6057) and abutment 
supported crown (D6058). 
 
You asked the Plan to pre-approve the custom fabricated abutment (D6057) and abutment supported crown 
(D6058). You say that the benefit eligibility does not differentiate between crowns over natural teeth and 
crowns over implants. You say that what the benefits cover should be clarified. The Plan denied your request. 
The Plan says the services are not covered benefits. 
 
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, 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 
custom fabricated abutment (D6057) and abutment supported crown (D6058).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower denture (D5120).
You asked the Plan to pre-approve the dental items. You say that an exception should be made. The Plan denied your request. The Plan says the requested provider is out of network. The Plan also says that dental services to be provided by an out of network provider are not covered.
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 and dentures are listed as covered, dental services to be provided out of network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower denture (D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the deluxe frames (V2025) for post-cataract surgery 
eyeglasses purchased on June 1, 2021. 
 
You asked the Plan to pay for deluxe frames. You say that these glasses should be covered as you received 
them following a medically necessary cataract surgery. The Plan denied your request. The Plan says they have 
agreed to reprocess the claim and pay for the lenses and scratch resistant coating. However, deluxe frames are 
not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover deluxe frames.  
 
You asked the Plan to pay for deluxe frames. Medicare does not cover upgrades for glasses provided post 
cataract surgery. This includes, but is not limited to, deluxe frames, tinting, progressive lenses, or anti-
reflective coating. Therefore, we decided that the Plan does not have to pay for the deluxe frames (V2025) for 
post-cataract surgery eyeglasses purchased on June 1, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing provided on February 9, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the drug testing. You say that the service was medically necessary. The Plan 
denied your request. The Plan says no prior authorization was obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the service at issue was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for the drug testing provided on February 9, 2021, by an out-of-
network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve vertebral axial decompression treatments. 
 
You asked the Plan to pre-approve vertebral axial decompression treatments. You say that this is medically 
necessary and should be allowed. The Plan denied your request. The Plan says coverage of this treatment 
requires that the PROMIS-29 form be filled out, which has not been done. 
 
The Plan must follow Medicare rules. Medicare rules say that there is insufficient scientific data to support the 
benefits of this technique. Therefore, VAX-D is not covered by Medicare. 
 
Although this may be appropriate for you, Medicare does not provide coverage for this treatment. There may 
be coverage available under Medicaid if certain criteria are met, but this is beyond the scope of Maximus' 
review. Therefore, we decided that the Plan does not have to pre-approve vertebral axial decompression 
treatments.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable ventilator (E0466). 
 
You asked the Plan to pre-approve a portable ventilator. You say that the item is medically necessary. The Plan 
denied your request. The Plan says the request for a home mechanical ventilator set in AVAPS mode that could 
be delivered by 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 a portable ventilator. Our reviewer says 
that  Our physician reviewer found  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator (E0466).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex superion device for the enrollee. 
 
You asked the Plan to pre-approve the Vertiflex superion device. You say that the Vertiflex superion device is 
medically necessary. The Plan denied your request. The Plan says this device and surgery are not covered by 
Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that investigational devices 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 Vertiflex superion device. Our 
physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and 
efficacy. 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 Vertiflex superion device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the Vertiflex superion device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on May 21, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the office visit. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent.
Therefore, we decided that the Plan does not have to pay for the office visit provided on May 21, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional acupuncture visits. 
 
You asked the Plan to pre-approve additional acupuncture visits. You say that acupuncture has helped you 
immensely and more visits are necessary. The Plan denied your request. The Plan says the requested visits 
exceed the benefit limit for acupuncture services. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the record shows that you have had 20 sessions this 
year, which is the maximum amount covered by Medicare. Therefore, we decided that the Plan does not have 
to pre-approve additional acupuncture visits.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing provided on May 21, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the drug testing. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the drug testing provided on May 21, 2021, 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 peripheral auricular nerve stimulation device (electro-acupuncture device).
You asked the Plan to pre-approve peripheral auricular nerve stimulation device. You say that your goal is to help alleviate the enrollee's current pain and increase the ability to participate in day-to-day activities with reducing or alleviating the need for use of opioid medications. The Plan denied your request. The Plan says the denial of authorization for this device is correct, because this device is being requested for electro-acupuncture stimulation which is not covered.
The Plan must follow Medicare rules. Medicare rules say that auricular peripheral nerve stimulation devices are not covered by Medicare. 
We looked at the file and Medicare rules. This device is not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of peripheral auricular nerve stimulation device have not been met. Therefore, we decided that the Plan does not have to pre-approve a peripheral auricular nerve stimulation device (electro-acupuncture device).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a spinal cord stimulator (63650).
You asked the Plan to pre-approve a spinal cord stimulator. You say that this is medically necessary. The Plan denied your request. The Plan says the requirements for coverage have not been met.
The Plan must follow Medicare rules. The rules say that a spinal cord stimulator trial can be covered only for patients who have undergone careful screening, evaluation and diagnosis by a multidisciplinary team prior to implantation. Such screening must include a psychological evaluation. The file does not show that a psychological evaluation has been conducted in conjunction with this request for a spinal cord stimulator trial. Therefore, we decided that the Plan does not have to pre-approve a spinal cord stimulator (63650).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a continuous glucose monitoring system (A9276).
You asked the Plan to preapprove the CGM. You say that you require this device to use with your pump. The Plan denied your request. The Plan says this is not a covered service.
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 the CGM have not been met. Specifically, the requested CGM device does not meet the definition of a therapeutic CGM. Non-Therapeutic CGMs are not covered by Medicare or the Plan. Therefore, we decided that the Plan does not have to preapprove a continuous glucose monitoring system (A9276).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acupuncture to be provided by the requested out-of-
network provider. 
 
You asked the Plan to pre-approve acupuncture. The Plan denied your request. The Plan says your request for 
an HMO exception for out of network services does not meet the requirements for approval. The records 
received do not indicate an emergent or urgent medical condition or are in need of specialized service. There 
are in-network provider(s) within a reasonable distance from your location that can provide this service or item. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 
acupuncture to be provided by the requested out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a MyoPro device (L8702).
You asked the Plan to pre-approve a MyoPro device. You say that the item is medically necessary. The Plan denied your request. The Plan says this item is considered investigational.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a MyoPro device have not been met. Therefore, we decided that the Plan does not have to pre-approve a MyoPro device (L8702).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a custom breast prosthesis (L8035).
You asked the Plan to pre-approve the artificial breast. You say that you require this custom prosthesis. The Plan denied your request. The Plan says custom breast prosthesis are not covered.
The Plan must follow Medicare rules. Medicare rules say that the additional features of a custom fabricated prosthesis (L8035) compared to a prefabricated silicone breast prosthesis has not been established, and therefore, if an L8035 breast prosthesis is billed, it will be denied as not reasonable and necessary. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the artificial breast have not been met. Therefore, we decided that the Plan does not have to pre-approve a custom breast prosthesis (L8035).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve out of network hearing services.
You asked the Plan to pre-approve out of network providers. You say that you prefer to see the requested
provider. The Plan denied your request. The Plan says the requested provider is out of 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 provider in
this case is not a network provider with the Plan. The Plan has network providers available who can provide the
services at issue in this appeal. We found no exception that would require the Plan to pre-approve these
services. Therefore, we decided that the Plan does not have to pre-approve out of network hearing services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the power seat elevation (E2300). 
 
You asked the Plan to pre-approve the power seat elevation. You say that the item is medically necessary. The 
Plan denied your request. The Plan says your request is not a covered benefit because Medicare does not 
consider this feature to be primarily medical in nature. 
 
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 the power seat elevation (E2300).
Appeal type: Transportation
Decision: Unfavorable

We decided the Plan does not have to provide coverage an exception to the routine transportation benefit of 50 miles one way.
You asked the Plan to provide coverage for an exception to the 50-mile limit for routine transportation. You say it is medically necessary to be transported to the requested provider. The Plan denied your request. The Plan says your request exceeds the transportation benefit per the Plan contract. The provider you need transportation for is 67 miles from your home one way.
Medicare does not cover routine transportation. The Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers routine transportation up to 50 miles one way from your home. Your request exceeds this benefit. Medicare does not make exceptions to supplemental benefits. Therefore, we decided that the Plan does not have to provide coverage an exception to the routine transportation benefit of 50 miles one way.