Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement graft on tooth #4 (D7953).  
 
You asked the Plan to pre-approve a replacement graft. You say that you are appealing the denial of dental 
services. The Plan denied your request. The Plan says that a bone replacement graft (D7953) is not covered by 
your dental 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. 
 
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 
bone replacement graft on tooth #4 (D7953).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the computed tomography (CT) of the 
abdomen provided on April 6, 2022. 
 
You asked the Plan to reduce the copayment for the CT of the abdomen. You say that prior to receiving this 
service, you were advised that your copay would be $40.00. The Plan denied your request. The Plan says this 
cost sharing was charged 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 $180 
copayment for advanced imaging services provided at a specialist's office under the Physician/Practitioner 
services benefit category.  
 
 
 
 
 You have been asked to pay a $180 copayment for the CT of the abdomen. This item/service falls within the 
Physician/Practitioner services 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 reduce the copayment for 
the computed tomography (CT) of the abdomen provided on April 6, 2022.  
 
Your complaint about being provided with misinformation by the receptionist is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the requested item is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says 
that the requested item is not medically reasonable and necessary in this case. Our physician reviewer found 
that the provided records document that the home ventilator is being requested for use in average volume 
assured pressure support (AVAPS) mode with auto-titration (AE), which could be provided by a BiPAP device 
with AVAPS and a back-up rate. Medicare does not cover ventilators when used to provide BiPAP therapy. 
 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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve octreotide depot. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has gastrointestinal 
hemorrhage from arteriovenous malformation of the colon. The Food and Drug Administration (FDA) has not 
stated that the requested drug is indicated for the enrollee's condition. The Medicare approved drug compendia 
do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. The 
octreotide depot is therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve octreotide depot.  
 
Local Coverage Determination (LCD) L33438 referenced by the Plan is not valid for the state of Montana and 
was not used in the MAXIMUS determination.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a mandibular advancement device (E0486). 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says that there is no documentation that indicates any of the criteria have been met. 
 
The Plan must follow Medicare rules. Medicare rules say that a custom-fabricated mandibular advancement 
oral appliance (E0486) is covered if specific criteria are met. 
 
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 device. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee has severe obstructive sleep apnea diagnosed with a polysomnogram on 1/21/20. A 
positive airway pressure titration was unsuccessful, and the enrollee is intolerant of continuous positive airway 
pressure (CPAP). The device has been ordered by a dentist. All of the Medicare requirements have been met 
for this device. 
 
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 device have been met. Therefore, we decided that the Plan has to pre-
approve a mandibular advancement device (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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home blood-pressure monitor (A4670). 
 
You asked the Plan to pre-approve a home blood-pressure monitor. You say that the requested item is a 
medical necessity for you. The Plan denied your request. The Plan says rules for coverage for ABPM have not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that ABPM is reasonable and necessary for the 
diagnosis of hypertension for beneficiaries with suspected white coat hypertension or with suspected masked 
hypertension. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a home blood-pressure monitor have not been met. Specifically, the provided medical records do 
not indicate a suspicion of white coat or masked hypertension. Therefore, we decided that the Plan does not 
have to pre-approve a home blood-pressure monitor (A4670).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee medical stability requires physician 
oversight, frequent monitoring, and intervention through physician face to face visits at least 3 times per week. 
You say that the enrollee's needs cannot be met safely in a lower level of care. The Plan denied your request. 
The Plan says an IRF admission is not medically necessary, and the enrollee can get the care they need at a 
lower level. 
 
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 that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like to stay in a hospital rehab facility, 
and you are no longer in pain while being able to take Tylenol as needed for pain. You say that you do not want 
to be sent to a skilled nursing facility because the closest one is 30 miles away. The Plan denied your request. 
The Plan says an IRF admission is not medically necessary. 
 
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 that you do not need frequent physiatry oversight for uncomplicated hip fracture 
repair. You do not require or have the capacity for intensive rehabilitation. 
 
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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that admission is a medical necessity. The Plan denied 
your request. The Plan says the enrollee does not require an intensive level of therapy requiring physician 
oversight. 
 
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 enrollee is medically stable and does not need physical medicine and 
rehabilitation physician's close supervision 3 times per week (at a minimum) for ongoing management of any 
active or acute exacerbations of chronic medical conditions. No nursing needs are documented. While the 
enrollee may benefit from physical therapy and occupational therapy, the enrollee's rehabilitation needs can be 
safely met in an alternate and low intensity setting such as in-home with therapies. 
 
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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the doctor said the enrollee was a perfect candidate 
for inpatient therapy. The Plan denied your request. The Plan says based on Medicare guidelines the inpatient 
rehabilitation facility services you are requesting do not meet the requirements for approval. 
 
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 enrollees nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  The enrollee was admitted for surgical repair of a femur fracture after a motor vehicle accident. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. While the medical records support a 
need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray exam of the cervical spine (72040) and the x-ray 
exam of the lumbar spine (72100) provided on April 12, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the x-ray exam of the cervical spine (72040) and the x-ray exam of the 
lumbar spine (72100) provided on April 12, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient diagnostic tests provided on July 
7, 2022. 
 
You asked the Plan to waive the copayment for outpatient diagnostic tests. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged 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 $35 
copayment for outpatient diagnostic tests.  
 
You have been asked to pay a $35 copayment for outpatient diagnostic tests. This item/service falls within the 
outpatient diagnostic tests benefits 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 outpatient 
diagnostic tests provided on July 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance and copayment for Medicare Part B 
Prescription Drugs, an outpatient diagnostic tests and a specialist office visit provided from July 14, 2021, to 
December 16, 2021. 
 
You asked the Plan to waive the coinsurance and copayment for Medicare Part B Prescription Drugs, an 
outpatient diagnostic tests and a specialist office visit. You say that you disagree with the cost share. The Plan 
denied your request. The Plan says this cost sharing was charged 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 20% coinsurance for Medicare Part B Prescription Drugs, $100 copayment for outpatient diagnostic tests and a $5 
copayment for a specialist office visit.  
 
You have been asked to pay a 20% coinsurance for Medicare Part B Prescription Drugs, $100 copayment 
outpatient diagnostic tests and a $5 copayment for a specialist office visit. The total allowed amount for the 
prescription drugs is $226.30. You are being asked to pay $45.26 ($226.30 x 20% = $45.26). The total amount 
you are being asked to pay is $180.26 ($100 +$45.26 + $5= $180.26). 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 
coinsurance and copayment for Medicare Part B Prescription Drugs, an outpatient diagnostic tests and a 
specialist office visit provided from July 14, 2021, to December 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power add-on to convert manual wheelchair to 
motorized wheelchair and labor component. 
 
You asked the Plan to pre-approve power add-on to convert manual wheelchair to motorized wheelchair and 
labor component. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says 
the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that the requested power add-on to convert manual 
wheelchair to motorized wheelchair is specifically not covered. 
 
We looked at the file and Medicare rules. The requested power add-on item at issue is not a covered benefit. 
Based on this information, we decided that Medicare rules for coverage of power add-on to convert manual 
wheelchair to motorized wheelchair and labor component have not been met. Therefore, we decided that the 
Plan does not have to pre-approve power add-on to convert manual wheelchair to motorized wheelchair and 
labor component.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the upgraded electronics (expandable controller, harness 
and electronic connector to 2 power options), replacement footrests, and transit option). 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says they denied the expandable controller, harness, and electronic connection device as not 
medically necessary. The Plan denied the transit kit as non-covered not primarily medical in nature. The Plan 
denied K0052 and K0043 as these codes are only used for replacement components and are not supposed to be 
used for the initial issuance of the device on account of being packaged into payment for the base wheelchair. 
 
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 the DME. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the provided records document that the patient has as 3-/5 bilateral upper extremity strength; 
documents also imply that the enrollee can meal prep and perform self-care with no other limitations reported 
in upper extremity function. Thus, available records indicate the enrollee has adequate upper extremity strength 
and function to operate the wheelchairs power options with their own switches. 
 
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 upgraded electronics (expandable controller, harness and electronic connector to 2 power 
options), replacement footrests, and transit option).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve and expandable controller and related accessories 
(E2377, E2313, E2311). 
 You asked the Plan to pre-approve and expandable controller and related accessories. You say that this 
equipment is medically necessary for the enrollee's control of their power wheelchair. The Plan denied your 
request. The Plan says the criteria for coverage of the expandable controller and related accessories have not 
been met. 
 
The Plan follows Medicare rules. Medicare rules say that an expandable controller and accessories are subject 
to the criteria listed 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 and expandable controller and related 
accessories. Our reviewer says that the requested expandable controller and accessories are not medically 
reasonable and necessary. Our physician reviewer found that in this case, the enrollee is non ambulatory and 
requires max assist with bathing but is independent in dressing, feeding, grooming and toileting. The enrollee 
has sufficient upper body capacity to manage standard switches and does not require the requested expandable 
controller to operate the approved power wheelchair. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of and expandable controller and related accessories have not been met. Therefore, 
we decided that the Plan does not have to pre-approve and expandable controller and related accessories 
(E2377, E2313, E2311).