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

 
We decided that the Plan does not have to pre-approve the elevating leg rest (CPT code E0990 X 2), skin 
protection wheelchair seat cushion (CPT code E2604), and general use wheelchair back cushion (CPT code 
E2611). 
 
You asked the Plan to pre-approve the durable medical equipment (DME). You say that the DME is medically 
necessary. The Plan denied your request. The Plan says the documentation does not show that you have a 
musculoskeletal condition or the presence of a cast or brace which prevents 90-degree flexion at the knee. The 
Plan states there is no documentation of significant edema of the lower extremities that requires elevating 
legrests. The Plan states you do not meet the criteria for a reclining back on the wheelchair and does not have a 
reclining back on the wheelchair. The Plan states the wheelchair has a captain's chair seat; therefore, E2611 
will be denied as not reasonable and not medically necessary. The Plan states the requested K0823 will provide 
the member appropriate support for seating on the captain's chair that K0823 comes equipped with. 
 
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 DME. Our physician reviewer 
found the documentation does not indicate that you have an indication for elevating leg rests or specialized 
cushions. You have been authorized for a captain's chair with cushions. The requested accessories are 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 the DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the elevating leg rest (CPT code E0990 X 2), skin protection wheelchair seat cushion (CPT code 
E2604), and general use wheelchair back cushion (CPT code E2611).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for periodic oral evaluation (D0120), and prophylaxis (D1110) provided by 
a participating provider on December 20, 2021. 
 
You asked the Plan to pay for periodic oral evaluation and prophylaxis. You say that you have not had a 
cleaning since June 18, 2021. The Plan denied your request. The Plan says that the member has already 
exhausted this benefit. 
 
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 has failed to provide evidence that D0120 and D1110 were previously 
provided. Therefore, we decided that the Plan has to pay for periodic oral evaluation (D0120), and prophylaxis 
(D1110) provided by a participating provider on December 20, 2021.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retainer crowns (D6740) for tooth #'s 12 and 14. 
 
You asked the Plan to pre-approve the retainer crowns. You say that you need the bridge for the two other 
crowns to hold onto. The Plan denied your request. The Plan says a bridge is only allowed if you are missing 
one front tooth. The Plan also says that your plan does not cover fixed bridges to replace missing posterior 
teeth. 
 
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. The Plan covers the retainer 
crowns 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 retainer crowns. Our reviewer says 
that the documentation provided does not meet the criteria for coverage for a fixed bridge replacing tooth #13 
using tooth #'s 12 and 14 as retainer crowns. Our physician reviewer found a review of the documentation does 
not indicate that tooth #13 has been removed. Also, the pre-treatment plan calls for core buildup for tooth #'s 12 
and 14 and does not indicate a pontic for tooth #13. Our reviewer found that the x-rays do not indicate a need 
for core buildup of teeth #12 and 14 and still show the presence of tooth #12. Our physician reviewer also 
found that this documentation does not show the need for the services. 
 
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 retainer crowns have not been met. Therefore, we decided that the Plan does 
not have to pre-approve retainer crowns (D6740) for tooth #'s 12 and 14.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care for the elective esophageal 
diverticulectomy (CPT code 43130). 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the stay is necessary. The Plan denied 
your request. The Plan says the planned procedure listed under CPT code 43130 is not listed on the CMS 
Inpatient Only List and the procedure is currently approved as an ambulatory procedure. The Plan states there 
is no documentation provided to support the expectation that you will require a greater than two (2) midnight 
stay.  The Plan states if you experience any peri- or post-operative complications, reconsideration for inpatient 
level of care can be performed on concurrent review with updated clinical information. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found this request is for inpatient admission/treatment following the procedure. The 
provided documentation, however, did not describe you as unstable or at a high risk for complication or other 
factors that would suggest an expectation that you would require hospital services that would likely cross two 
(2) midnights associated with this typically ambulatory procedure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care for the elective esophageal diverticulectomy 
(CPT code 43130).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265). 
 
You asked the Plan to pre-approve a total electric hospital bed.. You say that the electric hospital bed is 
medically necessary. The Plan denied your request. The Plan says this is not a covered benefit because the 
height adjustment feature is considered convenience. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed (E0265).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve  a power operated vehicle, group 1 standard, patient 
weight capacity up to and including 300 pounds (K0800). 
 
You asked the Plan to pre-approve the Power operated vehicle. You say that you need this power wheelchair 
because you have back problems and can barely walk. The Plan denied your request. The Plan says the records 
do not support that the enrollee meets the medical necessity criteria for the requested PMD. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 
 
 
 
 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 Power operated vehicle. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the documentation indicates that the enrollee has been receiving skilled 
therapy and has responded well to treatment. She is able to transfer independently and ambulate with a cane in 
the home. It is not clear what mobility-related activities of daily living she is unable to do in the home. In this 
case, the documentation indicates the enrollee is able to ambulate with a cane and transfer independently.  It is 
not clear that she would be unable to use a manual wheelchair if a wheelchair 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 the Power operated vehicle have not been met. Therefore, we decided that the 
Plan does not have to pre-approve  a power operated vehicle, group 1 standard, patient weight capacity up to 
and including 300 pounds (K0800).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation and panoramic x-rays 
(D0330 and D0150) provided on December 6, 2021. 
 
You asked the Plan to pay for the comprehensive oral evaluation and panoramic x-rays. You say that you 
would like reconsideration because you went to this dentist for more affordable care. The Plan denied your 
request. The Plan says this benefit has 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, the comprehensive oral evaluation and 
x-rays have a frequency limitation. The records shows that you received a comprehensive oral exam and 
panoramic x-rays in 2020. The frequency limitation for these services has been exceeded in this case. 
Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation and panoramic 
x-rays (D0330 and D0150) provided on December 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pulp vitality test (D0460), and cone beam CT capture 
with interpretation (D0364) provided on November 22, 2021. 
 
You asked the Plan to pay for the pulp vitality test and cone beam CT. You say that you went to the closest 
place listed. You say that it was 75 miles away. You also say that your root canal should be covered. The Plan 
denied your request. The Plan says pulp vitality test and cone beam CT are not listed as 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 pulp vitality test and cone beam CT 
are not among those covered under this benefit, regardless of the provider's network status. Therefore, we 
decided that the Plan does not have to pay for the pulp vitality test (D0460), and cone beam CT capture with 
interpretation (D0364) provided on November 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve twelve (12) dental implants (D6010). 
 
You asked the Plan to pre-approve dental implants. You say that these services are necessary. The Plan denied 
your request. The Plan says these services are not covered by your dental 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 
twelve (12) dental implants (D6010).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rocklatan Solution. 
 
You asked the Plan to pre-approve Rocklatan Solution. You say that the enrollee has tried multiple types of 
eyedrops. The Plan denied your request. The Plan says coverage of this medication is the responsibility of the 
enrollee's prescription drug plan. 
 
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 Rocklatan Solution.  
 
Benefits for Rocklatan Solution 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home health visit provided on January 7, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the home health visit. You say that it is the facilities reasonability to obtain 
authorization and it was medically necessary to treat the enrollee. The Plan denied your request. The Plan says 
the rendering provider is an out-of-network provider and there was no referral from an in-network provider or 
an approved authorization. Also, the service rendered was not urgent or emergent. 
 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 had network providers 
available who could have provided the items/services at issue in this appeal. 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. 
Therefore, we decided that the Plan does not have to pay for a home health visit provided on January 7, 2022, 
by an out-of-network (OON) provider.
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. You say that the records provided support the need for 
LTACH care. The Plan denied your request. The Plan says the guidelines for coverage have not been met. The 
Plan says that the enrollee's care can be provided in the current inpatient hospital. 
 
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 enrollee was admitted to acute care with sepsis and acute respiratory failure. The 
enrollee was treated with mechanical ventilation support and antibiotics complicated by needing chest tube. A 
trach was placed. Recent notes describe the enrollee as currently tolerating trach collar (off ventilation support) 
and is declining PEG tube but requiring NG tube feeds. The enrollee appears to be more stable and improving 
but feeding status is not stable without a PEG. They should only require short-term additional acute care 
services that can safely be completed at the current facility until more appropriate for a lower level of care. 
The enrollee does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the 
current facility. Transfer to an LTACH is not medically necessary at this time. Transfer to a lower level of care 
may be considered soon when treatment is completed and the feeding status is more stable. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Laboratory services provided on December 7, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for Laboratory services. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network and it was determined 
these services were not urgent or emergent. 
 
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 had network providers 
available who could have provided the items/services at issue in this appeal. 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. 
Therefore, we decided that the Plan does not have to pay for Laboratory services provided on December 7, 
2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for epidural steroid injections for the enrollee.
You asked the Plan to provide coverage for this treatment. You say that this treatment 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 stated that Maximus did not apply the correct Medicare coverage
criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for epidural steroid
injections.
The Maximus Physician Reviewer determined that the documentation provided in the case file supported that
the elements of the Medicare coverage criteria were met. The Plan requested a reopen and argues that the
Medicare rules were not met, as the enrollee did not have stenosis at any level.
Our Medical Director concluded that the Plan is correct in this case. The medical records show the enrollee is a
72-year-old man with low back pain which radiates to both feet. Imaging on November 30, 2021, revealed mild
degenerative disc disease in the lumbar spine with multilevel minimal bilateral foraminal narrowing, and no
significant central spinal canal stenosis. The clinical documentation which includes imaging of the spine does
not support that the coverage criteria as established by LCD L39036 were met in this case.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of this treatment have not been met. Therefore, we decided that the Plan does not
have to provide coverage for epidural steroid injections for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit provided on  December 21, 
2021. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that your specialist copay is 
$25 not $30. The Plan denied your request. The Plan says the copayment applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 
copayment for in-network specialist office visits. 
 
You have been asked to pay $30 for the office visit. A specialist office visit falls within the 
Physician/Practitioner services, including doctors office visits 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. Therefore, we decided that the Plan does not have 
to waive the copayment for the specialist office visit provided on  December 21, 2021.