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

We decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF)
admission and services for the enrollee.
You asked the Plan to provide coverage for IRF care. You say that at the time of the appeal, IRF admission was
medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria were not met.
Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the
correct criteria.
The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that IRF admission is
covered only when it is medically reasonable and necessary as described in the Medicare rules section.
The medical records show the enrollees abilities were described as significantly limited by pain, weakness, and
issues with dropping blood hemoglobin levels. This would hinder the enrollee's ability to participate in three
hours of therapy per day at least five days per week. Medicare rules for coverage of IRF care have not been
met. Therefore, we decided that the Plan does not have to provide coverage for acute inpatient rehabilitation
facility (IRF) admission and services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for an E0466 ventilator for the enrollee.
You asked the Plan to provide coverage for the requested ventilator. You say that the requested ventilator is
medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
Maximus overturned the Plans denial. The Plan requested a reopen and provided additional information.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for a ventilator
(E0466). Maximus overturned the denial for a lack of medical records in the file. The Plan requested a reopen
and provided the required medical records. The records show the enrollee is a 66-year-old man with a severe
restrictive ventilatory defect due to kyphoscoliosis, with chronic respiratory failure and hypercapnia, as well as
obstructive sleep apnea. On September 21, 2022, the treatment plan was to use BiPAP with AVAPS mode.
The medical records show no documentation of trial and failure of BiPAP with backup rate and AVAPS. The
documentation is insufficient to support that a home ventilator (E0466) is medically reasonable and necessary
in this case. Products classified as HCPCS code E0466, when used to provide CPAP or bi-level PAP (with or
without backup rate) therapy, regardless of the underlying medical condition, shall not be paid in the FSS
payment category. A ventilator is not eligible for reimbursement for any of the conditions described even
though the ventilator equipment may have the capability of operating in a bi-level PAP (E0470, E0471) mode. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as not 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 the requested ventilator have not been met. Therefore, we decided that the Plan
does not have to provide coverage for an E0466 ventilator for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet block injections (64493, 64494). 
 
You asked the Plan to pre-approve facet block injections. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that Facet Joint Interventions are considered medically 
reasonable and necessary for the diagnosis and treatment of chronic pain in patients who meet specific criteria. 
 
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 facet block injections. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the request is not medically 
necessary as the records do not have documentation of why a repeat radiofrequency ablation (RFA) cannot be 
performed. The review has determined that the enrollee does not meet the coverage criteria detailed in the 
LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet block injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet block injections (64493, 64494).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee is motivated to continue work in 
therapy and would benefit from a skilled therapy stay. The Plan denied your request. The Plan says the SNF 
services requested do not meet the requirements for approval. 
 
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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. The enrollee appears to be functioning at or near their baseline. Daily skilled services are 
not shown to be required to establish a maintenance program or to prevent deterioration of the enrollees 
condition. The enrollees care needs, custodial and intermittent, can be provided at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
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 requires an intensive inpatient program. 
The Plan denied your request. The Plan says the denial of 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 intensive 
rehabilitation services. 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cequa. 
 
You asked the Plan to pre-approve Cequa. You say that the enrollee is stable on Cequa, and this request is for a 
renewal of therapy. The Plan denied your request. The Plan says Cequa is a self-administered drug, and does 
not fall under Part B coverage. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Cequa.  
 
Benefits for Cequa may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 You asked the Plan to pre-approve home health services. You say that you would like to request 
reconsideration of the denied authorization. The Plan denied your request. The Plan says the services are not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the continued 
home health skilled nursing care and personal care assistance is not 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cone beam (D0380), an abutment supported to a 
crown (D6060), a pontic (D6242), and operating room services (D9500) for tooth #20, #21, and #22. 
 
You asked the Plan to pre-approve the dental services. You say that your dentist said your condition is serious 
and it should be covered. The Plan denied your request. The Plan says the pontic is denied because you are 
missing more than 1 upper front tooth or 2 lower front teeth. Also, the denial of authorization for the abutment, 
cone beam, and operating room services is correct because they are not covered by the 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. The Plan covers the dental 
services when the services are medically necessary and reasonable.  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 dental services. Our reviewer says 
that the pontic for tooth # 21 is not medically necessary. Our physician reviewer found that there appears to be 
an existing 3-unit bridge from teeth #20 to #22 in the supplied x-rays, however an implant supported bridge had 
been requested. The lack of periapical x-rays prevents a determination as to the need to remove the abutment 
teeth and place implants and a new bridge. Given the provided documentation, it is not reasonable to place an 
implant supported bridge from teeth #20 to #22. 
 
There needs to be 1 or 2 adjacent missing anterior teeth and no missing posterior teeth in order to satisfy the 
criteria. In this case the requested treatment is a 3-unit implant supported bridge replacing a posterior tooth. As 
the bridge is not replacing an anterior tooth, any coverage for such appliance would not be allowed. The 
requested pontic, being part of the denied posterior bridge, would therefore not be a covered service. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the pontic have not been met. The abutment, cone beam, and operating room 
services are not covered under the Plans dental benefit. Therefore, we decided that the Plan does not have to 
pre-approve a cone beam (D0380), an abutment supported to a crown (D6060), a pontic (D6242), and operating 
room services (D9500) for tooth #20, #21, and #22.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for fixed partial denture sectioning (D9120) provided on 
November 9, 2022. 
 
You asked the Plan to pay for fixed partial denture sectioning. You say that this should be covered. The Plan 
denied your request. The Plan says this is not a covered service. 
 
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 pay for fixed 
partial denture sectioning (D9120) provided on November 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for adjunctive pre-diagnostic test that aids in detection of 
mucosal abnormalities (D0431), gingival irrigation with a medicinal agent(D4921) and drugs or mendicants 
dispensed for home use (D9630) provided on November 9, 2022. 
 
You asked the Plan to pay for dental tests, medical agents, and drugs. You say that this should be covered. The 
Plan denied your request. The Plan says these are not covered services. 
 
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 pay for 
adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities (D0431), gingival irrigation with 
a medicinal agent(D4921) and drugs or mendicants dispensed for home use (D9630) provided on November 9, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for resin-based composites (D2392) provided on December 1, 
2022. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says the dental services were received from an out-of-network provider and are not covered 
by your supplemental 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. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for resin-based composites (D2392) provided on December 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device and related supplies 
provided on September 26, 2022. 
 
You asked the Plan to pay for the billed supplies. You say that the equipment was for use during surgery. The 
Plan denied your request. The Plan says the items are not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
 
 The claim shows the services at issue were provided in an ambulatory surgical center. Although the services 
may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we 
decided that the Plan does not have to pay for the pneumatic compression device and related supplies provided 
on September 26, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a sleep apnea custom oral appliance (E0486). 
 
You asked the Plan to pre-approve a sleep apnea custom oral appliance. You say that the item should be 
covered. The Plan denied your request. The Plan says that this provider does not participate in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not provide any documentation indicating this provider has opted 
out or is not certified with Medicare. Therefore, we decided that the Plan has to pre-approve a sleep apnea 
custom oral appliance (E0486).  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you will benefit from a daily skilled nursing facility 
with physical and occupational therapy. The Plan denied your request. The Plan says based on guidelines and 
the information we have about your condition, you don't meet the requirements, medically necessary care may 
be provided safely in a lower level of 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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) 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) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to provide coverage for IRF care. You say that at the time of the appeal, IRF admission was medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus is not apply the correct criteria. The Plan notes that the medical records show there were issues of weakness, fatigue and cognitive impairment noted by the hospital therapist.
The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. Based on the medical records provided, there was no indication at the time of the appeal that you would benefit from or have the ability to participate in the level of therapy provided during an IRF admission. Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral radiographic images (D0210) provided on 
January 17, 2023. 
 
You asked the Plan to pay for the dental service. You say that you went to a new dentist office, and they could 
not get your previous records. The Plan denied your request. The Plan says your benefit for the requested item 
or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on the date of service of October 26, 2020. 
Therefore, we decided that the Plan does not have to pay for the intraoral radiographic images (D0210) 
provided on January 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided from February 26, 
2022, to February 27, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the billed units 
are incorrect. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that the enrollee received only 1 day of inpatient care. However, 2 units/days were billed. The day of 
discharge should not be counted. Based on this information, we decided that Medicare rules for coverage of the 
billed services have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient 
hospital services provided from February 26, 2022, to February 27, 2022.