Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Gel-One. 
 
You asked the Plan to pre-approve Gel-One. You say that this drug is necessary for the enrollee's well-being. 
The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because the 
Plan requires a trial of Orthovisc, Synvisc, or Synvisc-One before it will approve Gel-One. 
 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 Gel-One. Our reviewer says that the 
enrollee does not meet the Medicare criteria for a step therapy exception for Gel-One. Our physician reviewer 
found the enrollee has not tried and failed the Plan's preferred drugs of Orthovisc, Synvisc, or Synvisc-One. 
The record does not show that these drugs would likely be less effective and/or 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 Gel-One have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of Gel-One.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve alveoloplasty in conjunction with extractions (code 
D7311), surgical removal of erupted tooth requiring removal of bone and/or sectioning of tooth (code D7210), 
and separation of one or more connections between retainer crowns (code D9120). 
 
You asked the Plan to pre-approve the dental services. The Plan denied your request. The Plan says 
alveoloplasty and separation of connections between retainer crowns are not covered by the dental benefit. 
Additionally, surgical removal of erupted tooth is only covered when performed by a participating general 
dentist. 
 
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, alveoloplasty in conjunction with 
extractions (code D7311) and separation of one or more connections between retainer crowns (code D9120) are 
not among those covered under this benefit. Surgical removal of erupted tooth (code D7210) is only covered 
when performed by a participating general dentist.  An oral surgeon is not considered a general dentist. 
Therefore, we decided that the Plan does not have to pre-approve alveoloplasty in conjunction with extractions 
(code D7311), surgical removal of erupted tooth requiring removal of bone and/or sectioning of tooth (code 
D7210), and separation of one or more connections between retainer crowns (abutment crown) and pontics 
(code D9120).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction of lower or sacral spinal facet joint nerves 
using imaging guidance represented by code 64635. 
 
You asked the Plan to pre-approve the facet joint procedure. You say that the enrollee has cancer in his pelvis 
and needs ablation to kill the cancer. You say that they want the pelvic procedure done to prevent the spread of 
cancer into the one marrow. The Plan denied your request. The Plan says the requested services are not 
medically necessary because the records show the enrollee does not have a history of facet-mediated pain or 
prior successful nerve blocks to the lumbar facets. 
 
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 facet joint procedure. Our reviewer 
says that the facet joint procedure is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has metastatic adenocarcinoma of the prostate with a metastatic lesion in 
the pelvis. Stereotactic body radiation therapy was administered previously. PET/CT has demonstrated that the 
lesion in the left iliac bone has gotten larger. The documentation does not support that a facet joint procedure is 
medically reasonable and necessary for the enrollee 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 the facet joint procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve destruction of lower or sacral spinal facet joint nerves using imaging guidance 
represented by code 64635.  
 
However, upon appeal the provider clarified that the service they were looking to have authorized was CT-
guided ablation of the iliac bone lesion to eliminate the focus of metastatic adenocarcinoma. The provider is 
noted to be in-network and it is expected that the Plan would work with the provider to determine which codes 
are correct for a given service. An enrollee should not be denied access to covered services due to the network 
provider requesting pre-authorization for the wrong codes. The Plan should create a request for the service that 
the in-network provider clarified they were looking to have authorized and make a determination regarding 
coverage of that service.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan of the abdomen and 
pelvis (74177) provided on October 14, 2021. 
 
You asked the Plan to pay for the CT scan services. You say that you would like this claim reprocessed and 
approved for payment based on the medical documentation submitted. The Plan denied your request. The Plan 
says this claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on November 19, 2021. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for the CT scan services have not been met. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan of the 
abdomen and pelvis (74177) provided on October 14, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
December 15, 2021. 
 
You asked the Plan to pay for home health services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services are not payable as billed.  
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the RAP 
claim should be submitted with only detail line 0023 with zero dollars per the guidelines. This means the claim 
was not submitted correctly. Therefore, we decided that the Plan does not have to pay for the home health 
services provided to the enrollee from December 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve maxillary partial denture (D5213) provided by a 
participating provider. 
 
You asked the Plan to pre-approve the dental services. You say that you need new dentures. The Plan denied 
your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service October 14, 2019. 
Therefore, we decided that the Plan does not have to pre-approve maxillary partial denture (D5213) provided 
by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral x-rays (D0220) provided on March 28, 2022. 
 
You asked the Plan to pay for the x-rays. You say that this x-ray should be covered. The Plan denied your 
request. The Plan says intraoral x-rays (D0220) are not covered by your routine 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 pay for intraoral 
x-rays (D0220) provided on March 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two gingival irrigations (D4921 x2) and a bone 
replacement graft for ridge preservation (D7953). 
 
You asked the Plan to pre-approve the gingival irrigations and bone replacement graft. The Plan denied your 
request. The Plan says these services are not covered under your benefit plan. 
 
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 two 
gingival irrigations (D4921 x2) and a bone replacement graft for ridge preservation (D7953).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve four gingivectomies or gingivoplasties (D4212 x4) and 
a bone replacement graft for ridge preservation (D7953). 
 
You asked the Plan to pre-approve the gingivectomies or gingivoplasties and bone replacement graft. You say 
that you need these services approved before your heart surgery, which is scheduled for August 1, 2022. The 
Plan denied your request. The Plan says these services are not covered under your benefit plan. 
 
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 four 
gingivectomies or gingivoplasties (D4212 x4) and a bone replacement graft for ridge preservation (D7953).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve native coronary artery catheterization with left heart 
catheterization (93458) for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that there is no documentation of a recent stress test that caused chest 
pain, abnormal EKG changes or abnormal cardiac rhythm. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The patient has been 
asymptomatic from a cardiac standpoint. A stress test has not been performed. Documentation does not support 
the rationale for this invasive imaging study. Guidelines do not support a need for cardiac catheterization in this 
setting. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these 
services. 
 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 native coronary artery catheterization with left heart catheterization (93458) 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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be 
provided at a lower level of care. 
 
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. The 
enrollee is medically stable and does not need physical medicine and rehabilitation physician's supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic 
medical conditions. There are no acute rehab nursing needs identified or documented. At the current functional 
level, the enrollee does not need intensive therapies consisting of at least 3 hours of therapy per day at least 5 
days per week with multidisciplinary approach in an IRF. While the enrollee may benefit from continued 
physical and occupational therapy, the enrollee's rehab needs can be safely provided in a lower intensity and 
alternate setting. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for 
IRF 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 inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gingival irrigation in all four quadrants (D4921) provided on 
March 24, 2022. 
 
You asked the Plan to pay for gingival irrigation. You say that the provider should have pre-authorized the 
services and you should not be responsible for them. The Plan denied your request. The Plan says gingival 
irrigation (D4921) is not covered by your routine 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 pay for gingival 
irrigation in all four quadrants (D4921) provided on March 24, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services rendered on November 17, 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 that the services were not performed for the enrollee. 
 
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 states that the services were not rendered; however, the documentation 
contains a laboratory report for the date of service at issue for this enrollee. The Plan has not provided any 
documentation or Medicare rules to support that the services cannot be covered. Therefore, we decided that the 
Plan has to pay for the laboratory services rendered on November 17, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. 
 
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 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 these services. Our reviewer says that 
the criteria for coverage are not met. Our physician reviewer found the records show that you have a mobility 
limitation but it is not specific that it impairs your ability to participate in one or more mobility-related 
activities of daily living (MRADLs) in the home. The documentation does not support that the mobility 
limitation cannot be sufficiently resolved by the use of an appropriate walker or manual wheelchair or that the 
scooter will significantly improve your ability to participate in MRADLs. There is no objective home assessment indicating you can safely maneuver the requested scooter in the home. 
The services are 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 a power scooter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), first 
intraoral periapical x-ray (D0220), and two additional intraoral periapical x-rays (D0230 x2) provided on April 
18, 2022. 
 
You asked the Plan to pay for the problem focused limited oral evaluation and intraoral periapical x-rays. You 
say that the doctor took it upon themself to take x-rays, without discussing the charges with you. You also say 
you find it unjust and unfair for you to be charged for these services. The Plan denied your request. The Plan 
says problem focused limited oral evaluation is not a covered expense under your dental plan. The Plan also 
says that your intraoral x-rays benefit has been satisfied and the frequency limitation has been exceeded. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, problem focused limited oral 
evaluation is not among those covered under this benefit. The contract says intraoral x-rays are limited to 1 
procedure code per calendar year. The record shows that you received a first intraoral periapical x-ray (D0220) 
on March 14, 2022, and your intraoral x-rays benefit has been exhausted. Therefore, we decided that the Plan 
does not have to pay for the problem focused limited oral evaluation (D0140), first intraoral periapical x-ray 
(D0220), and two additional intraoral periapical x-rays (D0230 x2) provided on April 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for home COVID-19 testing purchased on January 18, 2022.
You asked the Plan to pay for this testing. You say that you were told these tests were covered by Medicare and
insurance. The Plan denied your request. The Plan says these tests were covered when issued by Medicare at
giveaway sites and by facilities. At the time of purchase, home test kits purchased in commercial pharmacies
were not covered supplementally by health plans. Maximus overturned the Plans denial. The Plan requested a
reopen and stated that Maximus did not apply the correct coverage criteria.
The Plan is correct in this case. The Plan follows Medicare rules. Medicare did not cover home COVID-19 test
kits for Medicare enrollees under their Plan benefit. This test was used for preventative
screening purposes and was not covered by your Plan contract supplementally at the time of purchase.
Therefore, we decided that the Plan does not have to pay for home COVID-19 testing purchased on January 18, 2022.