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

We decided that the Plan does not have to pre-approve periodontal scaling and root planing for the enrollee.
You asked the Plan to pre-approve these dental services. You say that these dental services are medically
necessary. The Plan denied your request. The Plan says these dental services are not covered. Maximus
overturned the Plans denial. The Plan requested a reopen and stated Maximus did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for periodontal scaling
and root planing. The Maximus Dental Reviewer determined that the dentition in the lower left and right
quadrants is comprised of implants along with natural teeth. Implants must be treated as teeth since they are
susceptible to the same periodontal disease as natural teeth. The periodontal charting indicates that both the
natural teeth and implants have sufficient periodontal pockets for treatment. The combination of implants and
natural teeth comprise the minimum of four teeth per quadrant and the charting of the periodontal pockets
indicate the need for the treatment. The Plan argues that their criteria refer to natural teeth and not implants and
cannot be applied as they were. "According to the radiographs submitted, there are only 3 natural teeth in the
left lower quadrant, and 2 natural teeth in the lower right quadrant."
Our Medical Director has determined that the Plan is correct in this case. The Plan denied deep gum and root
cleaning in the lower left and lower right quadrants. The documentation does not support that the enrollee's
natural teeth comprise the minimum of 4 teeth per quadrant. As such, the coverage criteria are not met in this
case.
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 these dental services have not been met. Therefore, we decided that the Plan
does not have to pre-approve periodontal scaling and root planing for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the individual psychotherapy services (90832) provided April 26, 2021.
You asked the Plan to pay for the psychotherapy services. You say that this appeal should be granted because the services provided were medically necessary. The Plan denied your request. The Plan says there was no documentation of consultation with the attending or primary care physician in the enrollee's medical record.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked the file and Medicare rules. There was no referring provider on the claim and no indication in the medical records that the enrollee's primary care physician was consulted. 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 April 26, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a colonoscopy (45378).
You asked the Plan to pre-approve the colonoscopy. You say that the enrollee needs this service. The Plan denied your request. The Plan says the requested service is not medically reasonable or necessary.
The Plan follows 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 colonoscopy. Our reviewer says that the requested colonoscopy is not medically necessary. Our physician reviewer found the record indicates that the enrollee had a 1 mm hyperplastic polyp removed in 2016. The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service in the enrollee's clinical situation. The elements of the coverage criteria are not satisfied. Therefore, the reviewer found that the requested colonoscopy is recommended. 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 colonoscopy have not been met. Therefore, we decided that the Plan does not have to pre-approve a colonoscopy (45378).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided from July 2, 2021, to July 3, 2021.
You asked the Plan to pay for the self-administered drugs. You say that these drugs should be covered by your insurance because they were not self-administered. The Plan denied your request. The Plan says self-administered drugs are not covered services under your 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 pay for the self-administered drugs provided from July 2, 2021, to July 3, 2021.
Benefits for the self-administered drugs 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF 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 there is no need for physician supervision 3 times per week (at a minimum) for the
ongoing management of any active or acute exacerbations of chronic medical conditions. Based upon the current level of function, the enrollee does not require an intensive, complex, multidisciplinary approach to daily therapy. Documentation does not support the need for a therapy program consisting of at least 3 hours of therapy per day at least 5 days per week with an interdisciplinary approach to rehabilitation care. There are no documented skilled nursing needs. While the enrollee may benefit from physical therapy and occupational therapy, the rehabilitation needs can be safely met in an alternate and lower intensity setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit provided on July 1, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the domiciliary or rest home visit. You say that the enrollee is homebound because of dementia. The Plan denied your request. The Plan says this service was referred and rendered by non-participating providers. The Plan also says that prior authorization was not obtained.
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 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 the domiciliary or rest home visit provided on July 1, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more toward the bitewing x-ray, prophylaxis and comprehensive oral evaluation provided on April 22, 2021.
You asked the Plan to pay more toward the bitewing x-ray, prophylaxis and comprehensive oral evaluation. You say that you were told at the time of the appointment you would have to pay, and you would be reimbursed. You say that there was no mention of partial reimbursement and you did not need the x-rays they said were covered. The Plan denied your request. The Plan says the claim processed correctly.
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 Plan is only obligated to pay 50% of the allowed amount for bitewing x-rays and a prophylaxis from an out-of-network provider. A comprehensive oral evaluation is only covered once every three years. The Plan paid for the comprehensive oral evaluation provided on May 28, 2019, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay more toward the bitewing x-ray, prophylaxis and comprehensive oral evaluation provided on April 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on July 8, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not approved in advance.
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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services provided by an out-of-network provider on July 8, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laryngoscopy procedure you had at an
ambulatory surgery center on June 7, 2021.
You asked the Plan to waive the copayment for the laryngoscopy procedure. You say that you were told that
the deductible would be waived for this service. The Plan denied your request. The Plan says you were charged
this copayment correctly. In addition, the Plan stated that there are no records showing that you or the provider
contacted them to confirm your cost sharing obligations prior to the services.
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 $245
copayment for surgery or other services in an ambulatory surgery center.
You have been asked to pay a $245 copayment for the laryngoscopy procedure. The laryngoscopy procedure
falls within the surgery or other services in an ambulatory surgery center benefit category. There is no evidence
that the Plan provided you with incorrect information regarding this cost sharing. 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 laryngoscopy procedure you had at an ambulatory surgery center on June 7,
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the enteral nutrition (CPT code B4154), for the enrollee. 
 
You asked the Plan to pre-approve the enteral nutrition. You say that you highly recommend that the enrollee 
continues on Glucerna liquid diet health shakes by oral route, three (3) times a day. The Plan denied your 
request. The Plan says when taken orally it is not covered by Medicare. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the enteral nutrition have not been met. Orally administered enteral 
nutrition products, related supplies and equipment will be denied as non-covered. Therefore, we decided that 
the Plan does not have to pre-approve the enteral nutrition (CPT code B4154), for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the IRF care is medically necessary. The Plan denied 
your request. The Plan says an intensive rehabilitation program 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 the complexity of the enrollees nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does 
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-
disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the lower extremity prosthetic Flex-Walk system 
(L5981) and accessories (L5828, L5848, L5850, L5968). 
 
You asked the Plan to pre-approve the lower extremity prosthetic Flex-Walk system and accessories. You say 
that the items are medically necessary. The Plan denied your request. The Plan says the items are 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 the lower extremity prosthetic Flex-
Walk system and accessories. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested items exceed your medical 
need as the documentation does not support that you are a level K3 ambulator given the documentation that the 
expected ambulatory aid is a cane and walker. Furthermore, you are currently a K2 ambulator and the activities 
that you perform in the letter of medical necessity do not support that you require the requested items. 
 
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 lower extremity prosthetic Flex-Walk system and accessories have not been 
met. Therefore, we decided that the Plan does not have to pre-approve the lower extremity prosthetic Flex-
Walk system (L5981) and accessories (L5828, L5848, L5850, L5968).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF 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 there is no need for physician supervision 3 times per week (at a minimum) for the 
ongoing management of any active or acute exacerbations of chronic medical conditions. Based upon the 
current level of function, you do not require an intensive, complex, multidisciplinary approach to daily therapy. 
Documentation does not support the need for a therapy program consisting of at least 3 hours of therapy per 
day at least 5 days per week with an interdisciplinary approach to rehabilitation care. There are no documented 
skilled nursing needs. While you may benefit from physical therapy and occupational therapy, the 
rehabilitation needs can be safely met in an alternate and lower intensity setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy services. 
 
You asked the Plan to pre-approve the requested services. You say that you cannot do the exercises needed for 
the healing process. 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 medically necessary outpatient 
therapy. 
 
The file shows that 8 physical therapy visits were requested. 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 requested services. Our physician reviewer found that the requested therapy is not 
generally accepted as effective therapy for your condition beyond what was already approved by the Plan. You 
have had therapy authorized now that your weight bearing status of your upper extremity changed.  The documentation does not reveal that you will need additional therapy beyond what was authorized. You do 
not require the unique skills of a professional therapist are required to provide treatment, that the services can 
be performed only by a therapist, or under the supervision of a therapist. You can transition to a home exercise 
program. The specialized skill of a qualified therapist are not required to establish, design or deliver a program 
to maintain your current condition or to prevent or slow further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve physical therapy services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xiidra 5% drops. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says Xiidra is a self-administered drug. The Plan states the medication does not fall 
under Part B coverage. The Plan states the enrollee does not have pharmacy (drug) benefits administered by 
this Health Plan, but the enrollee does have pharmacy benefits through another vendor. 
 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 Xiidra 5% drops.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aduhelm. 
 
You asked the Plan to pre-approve Aduhelm. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the submission included no validated objective rating scale showing mild cognitive 
impairment or mild dementia. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Aduhelm. Our reviewer says that that 
Aduhelm is not medically reasonable and necessary. Aduhelm is not FDA-approved for your diagnosis. The 
FDA-approved label states that Aduhelm is "approved under accelerated approval based on reduction in 
amyloid beta plaques observed in patients treated with ADUHELM." The case file does not contain 
documentation of amyloid beta plaques. The use of Aduhelm is not supported by one of the major drug 
compendia or by clinical research that appears in a CMS-approved medical journal. Our physician reviewer 
found that your condition does not meet criteria for coverage of Aduhelm. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Aduhelm have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aduhelm.