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

 
We decided that the Plan does not have to pre-approve Easy MSUD tablets to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the requested services. You say that the in-network provider is not able to 
provide the supplement. The Plan denied your request. The Plan says the requested supplement is available at a 
contracted location. 
 
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 OON services. Therefore, we decided that the Plan does not have to pre-approve 
Easy MSUD tablets to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient care provided to the enrollee from April 4, 2020, to
April 8, 2020.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says the records provided do not support the DRG billed. Maximus overturned the case for a
lack of medical records. The Plan requested a reopen and provided the required medical records.
Our Medical Director looked at the case file and the reopen request. At issue is whether the billed DRG 871:
Septicemia or severe sepsis without mechanical ventilation treater than 96 hours with major complication or
comorbidity (MCC), is supported by the medical records. The medical records show the enrollee was a then 76-
year-old woman with a history of stroke, hypertension, Parkinson's disease, GERD, and chronic back pain,
who was admitted to the hospital on April 4, 2020, with altered mental status, suspected sepsis secondary to a
urinary tract infection, acute-on-chronic renal failure, and an elevated troponin. The enrollee was in no acute
distress. The enrollee was initially drowsy but arousable, and subsequently was alert and oriented x3.
WBC was elevated. Lactic acid was slightly elevated; a repeat level was normal. Cardiology consultation noted
that the mildly elevated troponin was probably secondary to baseline, versus underlying kidney injury, versus
NSTEMI. Urine culture results were not considered clinically significant. Sepsis has been defined by a 2016
SCCM/ESICM task force as life-threatening organ dysfunction caused by a dysregulated host response to
infection (Sepsis-3) as evidenced by organ dysfunction. The clinical documentation provided in the reopen
request supports that there is insufficient support for DRG 871: Septicemia or severe sepsis without
mechanical ventilation >96 hours with major complication or comorbidity.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay
for inpatient care provided to the enrollee from April 4, 2020, to April 8, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laminotomy, hemilaminectomy (63030) provided 
October 18, 2021. 
 
You asked the Plan to pay for the surgical procedure. You say that please review the attached supporting 
documentation. Please review and reprocess the claim accordingly upon review. The Plan denied your request. 
The Plan says the request for coverage is not medically necessary. 
 
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 pay for the surgical procedure. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was being treated for intervertebral disc disorders with radiculopathy of 
the lumbar region. The operative note indicated she had severe left thigh pain. She had L2 and L3 radiculopathy that has not responded to nonoperative treatment. However, detailed documentation is not 
evident regarding trial and failure of recent, reasonable, and comprehensive less invasive conservative care 
measures. Additionally, there were no diagnostic imaging studies provided to corroborate a pathology that 
could benefit from the procedure. There were no examinations provided for review that detailed any objective 
findings to corroborate the pathology. There are limited large-scale, long-term references showing the safety 
and efficacy of the requested surgery in this clinical setting. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the 
requested laminotomy (hemilaminectomy) is not medically reasonable or 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 surgical procedure have not been met. Therefore, we decided that the Plan 
does not have to pay for the laminotomy, hemilaminectomy (63030) provided October 18, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says the 
enrollee has no needs that would require the intensity of skilled nursing that is found in a LTACH. The Plan 
also says that the enrollee has no needs that would require daily physician visits for medical decision making or 
that would require the intensity of long-term acute care. 
 
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 services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the patient does not require, and there are no services at the LTACH that are not 
already available and covered at the current facility. Our reviewer also found that transfer to an LTACH is not 
medically necessary as it would not be clinically advantageous. 
 
 
 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 services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share amount for the ustekinumab (Stelara) (J3358) 
provided on January 31, 2022. 
 
You asked the Plan to waive the cost share amount for ustekinumab. You say that you were advised by the 
billing department that your intravenous (IV) infusion would be covered at 100%. You say that this was the 
only reason that you agreed to receive it. The Plan denied your request. The Plan says the drug processed 
correctly according to the Evidence of Coverage. 
 
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 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay 20% coinsurance for ustekinumab. Ustekinumab falls within the Medicare Part B 
prescription drugs benefit category. This means that 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. The record shows that the actual infusion service was covered. Therefore, we decided that the Plan does not have to waive the cost share amount for the ustekinumab (Stelara) 
(J3358) provided on January 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ankle-foot orthosis (L2330, L1940). 
 
You asked the Plan to pre-approve the orthosis. You say that the orthosis is medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that ankle foot orthoses (AFO) are covered for ambulatory 
beneficiaries with weakness or deformity of the foot and ankle.  
 
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 orthosis. Our reviewer says that the 
requested orthosis is not medically necessary. Our physician reviewer found the provided records do not 
document weakness or deformity of the foot and ankle as required under Medicare rules. 
 
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 orthosis have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an ankle-foot orthosis (L2330, L1940).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the requested device. You say that the enrollee is unable to prick his fingers. 
The Plan denied your request. The Plan says you do not meet the coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 
 We looked at the file and Medicare rules. The documentation does not indicate that you use insulin with at least 
three daily injections or require frequent self-adjustment of insulin dosage based on the blood glucose testing 
results. Based on this information, we decided that Medicare rules for coverage of the requested device have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a push wheelchair with features. 
 
You asked the Plan to pre-approve a push wheelchair with features. You say that the items are medically 
necessary. The Plan denied your request. The Plan says the member resides in a skilled nursing facility. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that a push wheelchair with features is being requested for use in a SNF or hospital. Therefore, 
we decided that the Plan does not have to pre-approve a push wheelchair with features.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the determination of refractive state (92015) provided on 
February 8, 2022. 
 You asked the Plan to pay for the determination of refractive state. You say that the treating provider is part of 
the Plan's network, and you received a routine vision exam. The Plan denied your request. The Plan says this 
service is not covered because it is not considered routine. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when the eye refractions are done during a routine exam. 
 
We looked at the file and the Plan's rules. The record shows that the determination of refractive state was 
provided during a medical examination and evaluation (92014), not a routine eye exam. Based on this 
information, we decided that the Plan's rules for coverage of the determination of refractive state have not been 
met. Therefore, we decided that the Plan does not have to pay for the determination of refractive state (92015) 
provided on February 8, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS device. 
 
You asked the Plan to pre-approve a CardioMEMS device. You say that the CardioMEMS implant is medically 
reasonable and necessary. The Plan denied your request. The Plan says the CardioMEMS device has been 
determined to be of uncertain value and carries risk of significant complications. The Plan says that the 
CardioMEMS device should only be approved for patients in a clinical trial. 
 
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 a CardioMEMS device. Our reviewer 
says that a CardioMEMS device is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there remains a dearth of randomized, blinded clinical studies examining long-term 
clinical outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the 
CardioMEMS system would not be considered medically appropriate 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 a CardioMEMS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS device.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the simple repair of superficial wounds (12014) provided on 
July 31, 2021. 
  You asked the Plan to pay for the simple repair of superficial wounds (12014). You say that a provider who 
prepares a separately identifiable interpretation which contributes to the diagnosis and treatment of the patient 
is entitled to payment. You say that the denied service should be reprocessed in accordance to CPT and CMS 
guidelines. The Plan denied your request. The Plan says an appropriate modifier was not billed with this code 
edit and the remaining codes were paid. 
 
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 12014 
is a column II code to column I code 21310. 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 the simple repair of superficial wounds (12014) provided on July 
31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) 
device provided on September 8, 2021. 
 
You asked the Plan to pay for the TENS device. You say that this device was medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage of the TENS device 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that in order for a transcutaneous electrical nerve 
stimulation (TENS) device to be covered, the beneficiary must be enrolled in an approved clinical study. Based 
on this information, we decided that Medicare rules for coverage of the TENS device have not been met. 
Therefore, we decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation 
(TENS) device provided on September 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213) and a mandibular 
partial denture (D5214). 
 
You asked the Plan to pre-approve the partial dentures. You say that you need the dentures. The Plan denied 
your request. The Plan says these services exceed the maximum count allowed per period. 
 
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, maxillary partial denture (D5213) and 
mandibular partial denture (D5214) are each limited to one procedure every five plan years. The record shows 
that you received a maxillary partial denture (D5213) and mandibular partial denture (D5214) on November 
10, 2020 and your maxillary partial denture (D5213) and mandibular partial denture (D5214) benefits have 
been exhausted. 
  
Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture (D5213) and a 
mandibular partial denture (D5214).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ultrasound, abdominal aorta, real time with image 
documentation, screening study for abdominal aortic aneurysm (AAA) provided on October 29, 2021. 
 You asked the Plan to pay for the ultrasound. You say that you go to the doctor every 5 years for an ultrasound, 
and it should be covered in full. The Plan denied your request. The Plan says you are covered for one 
abdominal aortic aneurysm screening, a one-time screening ultrasound for people at risk. You had an 
abdominal aortic aneurysm screening in 2016. The benefit has been exhausted. 
 
The Plan contract covers Abdominal aortic aneurysm screening. The Plan contract says the benefit is for a one-
time screening ultrasound for people at risk. 
 
We looked at the file, the Medicare rules and the Plans rules. The file shows that you received a one-time 
Abdominal aortic aneurysm screening in 2016 and the benefit has been exhausted. Therefore, we decided that 
the Plan does not have to pay for an ultrasound, abdominal aorta, real time with image documentation, 
screening study for abdominal aortic aneurysm (AAA) provided on October 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide coverage for additional routine transportation trips. 
 
You asked the Plan to provide coverage for additional routine transportation trips. The Plan denied your 
request. The Plan says the benefit has been exhausted. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage.  For that reason, the Plans coverage rules apply in this case. The Plan covers a maximum of 24 one-way trips 
per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to provide coverage for additional routine transportation trips.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) 
provided on November 12, 2021. 
 
You asked the Plan to pay for the ambulance service. You say that you fell and hurt your wrist. You say that 
the emergency medical service personnel came and checked you out. You say that you refused transport. You 
say that your wrist was broken. You also say that you feel this should be covered. The Plan denied your 
request. The Plan says since there was no transported provided, there is no payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on November 12, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no 
transport, (A0998) provided on November 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an evaluation for moderate sedation, deep sedation or 
general anesthesia (D9219) and therapeutic parenteral drug (D9610). 
 
You asked the Plan to pre-approve the evaluation and therapeutic parenteral drug. The Plan denied your 
request. The Plan says these services are not covered on your plan. 
 
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 an evaluation for moderate sedation, deep 
sedation or general anesthesia (D9219) and therapeutic parenteral drug (D9610).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on 
March 1, 2022. 
 
You asked the Plan to pay for the comprehensive oral evaluation. You say that it was not your choice to switch 
dentists, but you needed work done that the other provider could not complete. The Plan denied your request. 
The Plan says your benefits for this service have been satisfied and the frequency limitation has been exceeded. 
 
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, comprehensive oral evaluation 
(D0150) is limited to 1 procedure code every 3 calendar years. The record shows that you received a 
comprehensive oral evaluation (D0150) on February 4, 2020 and your comprehensive oral evaluation (D0150) 
benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive 
oral evaluation (D0150) provided on March 1, 2022.