Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Savella 50 mg tablet. 
 
You asked the Plan to pre-approve Savella. You say that this drug is medically necessary for your condition. 
The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical benefit? 
 
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 Savella 50 mg tablet.  
 
 
 
 Benefits for Savella 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 pre-approve Dexcom G6 therapeutic continuous glucose monitor 
(CGM) receiver transmitter and sensor. 
 
You asked the Plan to pre-approve the Dexcom G6 CGM. You say that the records provided should support the 
necessity of the requested service. The Plan denied your request. The Plan says the enrollee does not meet the 
Medicare criteria because she does not receive at least 3 insulin injections per day and is not on a continuous 
insulin infusion pump. 
 
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 perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the Dexcom G6 CGM have not been met. 
Therefore, we decided that the Plan does not have to pre-approve Dexcom G6 therapeutic continuous glucose 
monitor (CGM) receiver transmitter and sensor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a removal of lateral exostosis (D7471). 
 
You asked the Plan to pre-approve the removal of lateral exostosis. You say that your dental provider says you 
need to have oral surgery to remove the bony buildup prior to getting teeth extracted for dentures. You also say 
that the dentures will not fit in your mouth without having the bony buildup removed. The Plan denied your 
request. The Plan says this service is not covered under your benefit package. 
 
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 a 
removal of lateral exostosis (D7471).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xeljanz 5 mg tablet. 
 
You asked the Plan to pre-approve Xeljanz. You say that this is medically reasonable and necessary. The Plan 
denied your request. The Plan says this drug is not covered under the enrollee's medical benefit. 
 
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 Xeljanz 5 mg tablet.  
 
Benefits for Xeljanz 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Esophagogastroduodenoscopy (EGD). 
 
You asked the Plan to pre-approve an EGD. You say that an EGD is medically necessary. The Plan denied your 
request. The Plan says an EGD 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 pre-approve an EGD. Our reviewer says that the 
EGD is not considered medically reasonable and necessary in this case. Our physician reviewer found that no 
records were provided that support gastroesophageal reflux disease (GERD) is complicated, refractory to 
medical management, nor that there are red flags that warrant a repeat EGD at this time based on the enrollees 
health Plan's provided coverage guidance EGD 1.2, 1.3, and 1.7. The enrollee has not been shown to have 
Barrett's esophagus nor gastric intestinal metaplasia.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an EGD have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an EGD.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the SNF admission. You say that the requested admission to a SNF is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a SNF is not 
medically necessary. 
 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 the SNF admission. Our reviewer says 
that you do not meet the Medicare criteria for SNF care. 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. Although further rehabilitation services would be 
appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a 
lower level of care than a skilled nursing facility. 
 
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 SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the individual psychotherapy services (90832) provided July 
26, 2021. 
 
You asked the Plan to pay for the psychotherapy services. You say that you are requesting review of the 
documents and process the claim for payment. The Plan denied your request. The Plan says the information 
submitted does not support this level of service. 
 
The Plan must follow Medicare rules. If consultations are unsuccessful, document the patients medical chart 
with the date and physician notification method.  
 
We looked at the file, and Medicare rules. The submitted claim shows that the referring provider listed on the 
claim is also the servicing provider. Based on this information, we decided that Medicare rules for coverage of 
the psychotherapy services have not been met. Therefore, we decided that the Plan does not have to pay for the 
individual psychotherapy services (90832) provided July 26, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on June 28, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a 
laboratory setting; however, the file shows that the specimen was obtained in a community mental health center 
setting and should have been billed with POS code 53. Therefore, we decided that the Plan does not have to 
pay for the laboratory services rendered on June 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the guided tissue regeneration (D4266 x 2), implants (D6010 
x 2), socket preservation (D7953 x 2), custom abutments (D6057 x 2), abutment supported crowns (D6058 x 
2), and denture reline (D5731) provided on August 4, 2021. 
 
You asked the Plan to pay for the dental services. You say that you fell off your bike. You say that you may 
have sustained the injuries to your mouth at that time. You say that your only option for repair was to have 4 
implant teeth. You also say that you were advised your insurance would cover these services. The Plan denied 
your request. The Plan says the services you received are routine dental. The Plan says that the routine dental 
services are not covered by Medicare or the Plan.  
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for the guided tissue regeneration 
(D4266 x 2), implants (D6010 x 2), socket preservation (D7953 x 2), custom abutments (D6057 x 2), abutment 
supported crowns (D6058 x 2), and denture reline (D5731) provided on August 4, 2021.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for the two consultations. We decided that the Plan does not have to pay 
more for the extraction.  
 
You asked the Plan to pay for the two consultations and to pay more for the extraction. You say that your 
claims have been denied through a provider that is in-network. The Plan says that you are covered for specialist 
office visits at a $50.00 copayment responsibility. The Plan also says that tooth extractions have a 20% 
coinsurance responsibility, and the amount of $22.27 was applied correctly. 
 
We decided that the Plan has to pay for the two consultations.  
 
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. You were seen for a consultation and a possible tooth infection which the Plan 
assessed you owe a $50 copayment for each of these visits. The 2021 Evidence of Coverage clearly states that 
you are allowed two periodic oral evaluations, extensive oral exams, or re-evaluations-limited problem focused 
every 12 months, and you are also allowed three limited oral exams per 12 months. The Plan applied specialist 
copays for these exams, but the records do not show that these exams were provided due to a medical situation. 
The documentation also does not show that you have exceeded either one of the exam benefits. Therefore, we 
decided that the Plan has to pay for the two consultations.  
 
We also decided that the Plan does not have to pay more for the extraction. 
 
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, you are responsible for a 20% 
coinsurance for extractions. Therefore, we decided that the Plan does not have to pay more for the extraction. 
 
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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ferumoxytol (Q0138). 
 
You asked the Plan to pre-approve Ferumoxytol. You say that this drug is medically reasonable and necessary 
for the enrollee's condition. The Plan denied your request. The Plan says step therapy criteria have not been 
met. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Ferumoxytol. Our reviewer says that 
the requested drug is medically reasonable and necessary. Our physician reviewer found the Plan requires a 
trial of drug Infed and Venofer before they will approve the requested drug. In this case the patient has not tried 
and failed the required drug(s). There is no documentation provided indicating that the plans required drug(s) 
would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Ferumoxytol have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Ferumoxytol (Q0138).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the immunohistochemistry (IHC) testing provided on 
September 28, 2021, billed with code 88342. 
 
You asked the Plan to pay for the IHC testing as billed. You say that this should be covered. The Plan denied 
your request. The Plan says the Column 2 code was not billed with the required modifier.  
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 88342 
is a column II code to column I code 88323. 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 immunohistochemistry (IHC) testing provided on September 
28, 2021, billed with code 88342.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis (D1110) provided on October 20, 2021. 
 
You asked the Plan to pay for the prophylaxis. You say that you need three cleanings per year as recommended 
by your dentist. You also say that by doing this you have avoided dental surgery. The Plan denied your request. 
The Plan says this procedure is limited to twice per calendar year. The Plan also says that you have exceeded 
the frequency limitation for this 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, you are limited to two routine 
cleanings per calendar year. The record shows that you received cleanings on February 2, 2021, and June 15, 
2021 and your cleanings benefit has been exhausted. Therefore, we decided that the Plan does not have to pay 
for the prophylaxis (D1110) provided on October 20, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive any of the cost share for the wound debridement, office visits
and Unna boot application provided from March 25, 2021, to April 14, 2021.
You asked the Plan to waive this cost share. You say you do not believe this cost share is correct. The Plan
denied your request. The Plan says this cost share was applied correctly. Maximus partially overturned the
Plans denial. The Plan requested a reopen and provided additional information. The Plan states that the
descriptions of the codes billed by the provider are surgical codes. Your appeal explains these services were
rendered in an operating room at the hospital not a physician office. The Plan contract clearly states there is a
$360 copayment for outpatient surgical services. In this case, you are being charged $201.16 which is less than
the normal copayment.
The Plan is correct in this case. 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 $360 for outpatient surgical services and supplies. For the services rendered you are
being asked to pay less than the normal copayment expectation. 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 cost share for the wound debridement, office visits and Unna boot application provided
from March 25, 2021, to April 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve rebase complete lower denture (D5711). 
 
You asked the Plan to pre-approve the dental service. You say that you need this service to be approved 
immediately due to your dentures. The Plan denied your request. The Plan says rebase complete lower denture 
is not listed as 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 rebase complete lower 
denture is not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pre-approve rebase complete lower denture (D5711).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional level of epidural steroid injections (64484).
You asked the Plan to pre-approve an additional level of epidural steroid injections. You say that this procedure is medically necessary. The Plan denied your request. The Plan says this request exceeds the enrollee's needs.
The Plan follows Medicare rules. Medicare rules say that it is not considered medically reasonable and necessary for more than one spinal region to be injected in the same session. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve an additional level of epidural steroid injections. Our reviewer says that this procedure is not medically reasonable and necessary. Our physician reviewer found this 68-year-old gentleman has bilateral radicular pain in both lower extremities. He has failed conservative therapy and the request is for 2 levels bilaterally of Transforminal Epidural Steroid injections. The request exceeds the utilization criteria of the LCD. Therefore, only one level bilaterally may receive Transforminal steroids. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an additional level of epidural steroid injections have not been met.
Therefore, we decided that the Plan does not have to pre-approve an additional level of epidural steroid injections (64484).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the allograft (20930) provided on June 14, 2021. 
 
You asked the Plan to pay for the allograft. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says CPT code 20930 has a status indicator of B. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 20930 is not supported in the record. Specifically, CPT code 20930 has a status 
indicator of B. This means that the payment for CPT code 20930 is always bundled into the payment for 
another service. Based on this information, we decided that Medicare rules for coverage of the allograft have 
not been met. Therefore, we decided that the Plan does not have to pay for the allograft (20930) provided on 
June 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewing x-ray (D0270) provided on October 28, 2021. 
 
You asked the Plan to pay for the dental service. You say that your policy indicates visits to dentist are free of 
charge up to $1,000 in any one year period. You say that there is no frequency of visits limitation given. You 
also say that there is a $0 copayment for diagnosis services. The Plan denied your request. The Plan says 1 set 
of bitewing x-rays is covered per plan year. The Plan also says that the frequency limit 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and bitewing x-ray is listed as covered, 
the frequency limit of 1 set per plan year has been exceeded. The record shows that the Plan paid for bitewing 
x-rays that you received on January 12, 2021. Therefore, we decided that the Plan does not have to pay for the 
bitewing x-ray (D0270) provided on October 28, 2021.