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

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) 
and related supplies. 
 
You asked the Plan to pre-approve a CGM and related supplies. You say that the requested supplies are a 
necessity for your care. The Plan denied your request. The Plan says rules for coverage for CGMs and related 
supplies have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
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 assess adherence to their CGM regimen and diabetes treatment 
plan. 
 We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of a CGM and 
related supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre continuous glucose monitor (CGM) and related supplies.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network occupational therapy services for the enrollee.
You asked the Plan to pay for out of network providers. You say that this treatment is medically necessary. The Plan denied your request. The Plan says there are providers in network who can treat the enrollee. Maximus administratively overturned the Plans denial because a Plan contract was not submitted with the case file. The Plan requested a reopen and submitted a full copy of the Plan contract.
The Plan is correct in this case. 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have rendered these services. The Plan refused prior authorization for out of network services. Therefore, we decided that the Plan does not have to pay for out of network occupational therapy services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam computed tomography image (D0383) provided 
on February 14, 2022. 
 
You asked the Plan to pay for a cone beam computed tomography image. You say that this service was 
medically necessary. The Plan denied your request. The Plan says the service at issue is not a covered benefit. 
 
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 pay for a cone 
beam computed tomography image (D0383) provided on February 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services (D0150, D2752, D2950) on May 16, 2022, 
and May 25, 2022. 
 
You asked the Plan to pay for the dental services. You say that the dentist performed services that she did not 
know would not be approved. 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 Plans 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 services were exhausted between dates of service March 28, 2022 and 
May 16, 2022. Therefore, we decided that the Plan does not have to pay for dental services (D0150, D2752, 
D2950) on May 16, 2022, and May 25, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme. 
 
You asked the Plan to pre-approve Feraheme. You say that the requested Feraheme is medically necessary. The 
Plan denied your request. The Plan says the enrollee must try and fail Venofer, Ferrlecit, and Infed first. 
 
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 Feraheme. Our reviewer says that the 
Plan's step therapy criteria have not been met. Our physician reviewer found based on the medical records 
provided there is no indication that you have tried and failed the required drug(s). Based on the medical records 
provided and the Medicare-approved major drug compendia there is no indication that the plan's required 
drug(s) would likely be less effective and/or likely have adverse effects for you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Feraheme have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Feraheme.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an all lower extremity prostheses, multi-axial rotation unit 
(L5986), an addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control 
feature (L5856), an addition, endoskeletal, knee-shin system, stance flexion feature (L5845), an addition, 
endoskeletal knee-shin system, single axis, fluid swing and stance phase control (L5828) and an addition to 
endoskeletal knee-shin system, fluid stance extension, dampening feature (L5848). 
 
You asked the Plan to pre-approve the requested prosthetics. You say that you require the requested prosthetics 
which is medically necessary because the microprocessor knee will help you reach and maintain your 
functional state within a reasonable period, and you are extremely motivated to ambulate and return to your 
independence. The Plan denied your request. The Plan says that the requested microprocessor knee exceeds 
your need and is not reasonable and necessary per Medicare criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 prosthetics. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found clinical documentation shows that you are at a K3 level functionality, but you require a 
prosthetic to assist ambulation with dynamic balance/terrain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of prosthetics have been met. Therefore, we decided that the Plan has to pre-
approve an all lower extremity prostheses, multi-axial rotation unit (L5986), an addition to lower extremity 
prosthesis, endoskeletal knee-shin system, microprocessor control feature (L5856), an addition, endoskeletal, 
knee-shin system, stance flexion feature (L5845), an addition, endoskeletal knee-shin system, single axis, fluid 
swing and stance phase control (L5828) and an addition to endoskeletal knee-shin system, fluid stance 
extension, dampening feature (L5848).  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Temazepam. 
 
You asked the Plan to pre-approve Temazepam. You say that the medication is necessary. The Plan denied 
your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
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 Temazepam.  
 
Benefits for Temazepam 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an apicoectomy (D3410) provided on December 16, 2021. 
 
You asked the Plan to pay for the dental services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says an apicoectomy (D3410) 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 pay for an 
apicoectomy (D3410) provided on December 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the low-level laser treatment (S8948) and the office visit 
(99212) provided from March 24, 2022, through March 30, 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 covered under your 
contractual policy or by Medicare. 
 
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 low-level laser treatment (S8948) and the office visit (99212) 
provided from March 24, 2022, through March 30, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided on January 25, 2022, under the
Medicare benefit.
You asked the Plan for to pay for these services. You say that you do not believe this bill is correct. The Plan
denied your request. The Plan says these services must be addressed under your Medicaid benefit. Maximus
overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan says
that this claim denied under your Medicare benefit because you are Medicaid eligible. The Plan included
documentation to show that you are Medicaid eligible. The Plan says that Medicare pays covered dually
eligible beneficiaries' medical services first, because Medicaid is generally the payer of last resort. Medicaid
may cover medical costs that Medicare may not cover or partially covers (such as nursing home care, personal
care, and home- and community-based services). These services qualified under the Medicaid coverage.
The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all
cost sharing and coverage information. Your contract states dual eligible enrollees will have services that are
covered by either Medicare or Medicaid, but not by both. The services provided fall under your Medicaid
coverage and not your Medicare coverage. The IRE does not have jurisdiction over your Medicaid benefits.
Therefore, we decided that the Plan does not have to pay for medical services provided on January 25, 2022,
under the Medicare benefit.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the graft repair services coded 63710 provided on March 21, 2022. 
 
You asked the Plan to pay for the graft repair services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not separately payable. 
 
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, the CPT Code Manual definition of code 63710 is dural graft, spinal. 
 
We find that CPT code 63710 is not supported in the medical record. Specifically, this service is part of a 
global surgical fee. This service was billed within the global surgical period of major surgical procedures coded 
22612 (arthrodesis), 22830 (exploration of spinal fusion), and 63042 (laminotomy) by the same provider. 
Post-operative visits performed during the postoperative period of a global surgery that are related to the 
recovery from that surgery are included in the global surgical package. This code was not billed with the 
appropriate modifier indicating that the services billed were staged or unrelated to the post-operative period of 
a global period. This means this code is not payable as billed. Based on this information, we decided that 
Medicare rules for coverage of the graft repair services have not been met. Therefore, we decided that the Plan 
does not have to pay for the graft repair services coded 63710 provided on March 21, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy (PT) services provided on 
February 25, 2022. 
 
You asked the Plan to waive the copayment for the PT services. You say that you were not aware that you 
would owe $30 for each visit. The Plan denied your request. The Plan says you have been charged the correct 
cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 
copayment for each physical therapy visit.  
 You have been asked to pay a $30 copayment for the PT services. The PT services fall within the Outpatient 
Rehabilitation 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 waive the copayment for physical 
therapy (PT) services provided on February 25, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services provided on May 25, 2021, 
to November 10, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for outpatient mental health services. You say that you would like to appeal the 
denial of the claim. The Plan denied your request. The Plan says the provider is out-of-network, and it was 
determined these services can be received in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for outpatient mental health services provided on May 
25, 2021, to November 10, 2021, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the life sustaining oxygen and oxygen supplies (A0422) provided on July 20, 2021.

You asked the Plan to pay for the life sustaining oxygen and oxygen supplies. You say that this was an emergency transport. The Plan denied your request. The Plan says the life sustaining oxygen and oxygen supplies cannot be billed separately.

The Plan must follow Medicare rules. Medicare rules say that ambulance supplies are considered part of the general ambulance service and payment for them is included in the payment rate for the transport. Therefore, we decided that the Plan does not have to pay for the life sustaining oxygen and oxygen supplies (A0422) provided on July 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for full mouth debridement (D4355) provided on May 5, 2022. 
 
You asked the Plan to pay for full mouth debridement (D4355). You say that you were not aware the dentist 
was performing a full mouth debridement. The Plan denied your request. The Plan says this service is not 
covered under your 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 full mouth debridement 
(D4355) is not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pay for full mouth debridement (D4355) provided on May 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 3, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that due to the patient misleading the office by presenting 
the incorrect insurance card, the office was unable to obtain authorization. The Plan denied your request. The 
Plan says the provider is out-of-network and authorization is required prior to an out-of-network visit. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on May 3, 2022, by an 
out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99309) and 
psychotherapy, 30 minutes, (90833) provided on February 14, 2022. 
 
You asked the Plan to pay for the nursing facility care. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the enrollees claim would be covered under Original Medicare as it is 
responsible for coverage of Part B benefits starting on the date of election until the last day of the month in 
which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage 
before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the subsequent nursing facility care (99309) and 
psychotherapy, 30 minutes, (90833) provided on February 14, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the direct skilled nursing services of a registered nurse (RN) 
(G0299) provided on March 9, 2022. 
 
You asked the Plan to pay for the skilled nursing services. You say that you would like this claim to be 
reconsidered for payment. The Plan denied your request. The Plan says this claim was processed correctly, and 
is not eligible for a RAP claim reimbursement. 
 
The Plan must follow Medicare rules. Medicare rules say that all Home Health Agencies (HHAs) must submit 
a request for anticipated payment (RAP) within 5 calendar days after the start of care date for initial 30-day 
periods and within 5 calendar days after the from date for each subsequent 30-day period of care, which is set 
at 0 percent at the beginning of every 30-day period. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the skilled nursing services have not been met. Specifically, the record indicates the RAP was not 
submitted within 5 days of the from the start of care date. Therefore, we decided that the Plan does not have to 
pay for the direct skilled nursing services of a registered nurse (RN) (G0299) provided on March 9, 2022.