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

 
We decided that the Plan does not have to pre-approve the CardioMEMS device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is not enough evidence that the requested device would improve outcomes. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there remains a dearth of randomized, blinded clinical studies examining long-term clinical 
outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the 
CardioMEMS system would not be considered medically appropriate and necessary in this patients clinical 
management. 
 
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 not been met. Therefore, we decided that the Plan does not have 
to pre-approve the CardioMEMS device for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a restorative procedure (D2999), dentoalveolar structure
surgery (41899), and a crown (D2740).
You asked the Plan to pre-approve these services. You say that the current crown is cracked, and it is now
loose. You also say you are afraid it is going to fall off. The Plan denied your request. The Plan says these
services are not covered by your Plan's dental benefit. Maximus partially overturned the Plan's denial. The Plan
requested a reopen.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a
restorative procedure (D2999), dentoalveolar structure surgery (41899), and a crown (D2740).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a supply allowance for a continuous glucose monitor 
(K0553). 
 
You asked the Plan to pre-approve a supply allowance for a CGM. You say that you need to control your 
diabetes. You also say your doctor feels that this is the best way to keep on top of your sugar levels. The Plan 
denied your request. The Plan says you do not meet coverage criteria for approval of the requested CGM. 
 
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 the enrollee does not use insulin 
with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a supply 
allowance for a CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
supply allowance for a continuous glucose monitor (K0553).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM) 
and receiver (K0553, K0554). 
 
You asked the Plan to pre-approve a Freestyle Libre 2 CGM and receiver. You say that the prescription of the 
CGM is the most appropriate option for the enrollees condition. The Plan denied your request. The Plan says 
the enrollee does not meet coverage criteria for approval of the requested CGM. 
 
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 the enrollee does not use insulin 
with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a Freestyle 
Libre 2 CGM and receiver have not been met. Therefore, we decided that the Plan does not have to pre-approve 
a Freestyle Libre 2 continuous glucose monitor (CGM) and receiver (K0553, K0554).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64628). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the procedure is medically necessary 
due to the enrollee's chronic pain. The Plan denied your request. The Plan says the procedure is unproven and 
not medically necessary procedures are not covered by Medicare. 
 
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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the intracept procedure is experimental. More research is needed. The procedure is 
unproven and not medically necessary due to insufficient evidence of efficacy. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure (64628).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer (CPT code J1439). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the Medicare rules have not been 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 medication. Our physician reviewer 
found Injectafer is indicated for the treatment of iron deficiency anemia for the treatment of iron deficiency 
anemia intolerant of oral iron, in those who do not absorb iron, or anemia with ongoing blood loss. This 
enrollee does not have documented iron deficiency anemia prior to treatment of Injectafer. A ferritin was 814 
with an iron saturation of 25% which are not indicative of iron deficiency anemia. The service was 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 the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Injectafer (CPT code J1439).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the substance abuse treatment facility services provided from
January 11, 2022, to February 7, 2022, by an out-of-network (OON) provider.
You asked the Plan to pay for the substance abuse treatment facility services. You say that you spoke to your
doctor that recommended that you got treatment immediately. The Plan denied your request. The Plan says that
the services were provided out-of-network and 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. You have not provided any records to show these services were
emergent and could not have been provided by a network provider. 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 the substance abuse treatment facility services provided from January 11, 2022, to February
7, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Oxervate Sol 20mcg/Ml. 
 
You asked the Plan to pre-approve a medication. You say that the requested medication is medically necessary 
for the enrollee. The Plan denied your request. The Plan says the enrollee does not have pharmacy (drug) 
benefits administered by the Plan. 
 
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. The records show that the enrollee has an MA only plan. The enrollee 
does not have a pharmacy benefit with this plan. Based on this information, we decided that Medicare rules for 
coverage of a medication have not been met. Therefore, we decided that the Plan does not have to pre-approve 
Oxervate Sol 20mcg/Ml.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspiration for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the clinical value and effectiveness of bone marrow aspirate in the setting of spinal 
fusion surgery have not been demonstrated in the peer-reviewed literature. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the health plan approved the L4-5 transforaminal lumbar interbody fusion and inpatient stay. 
However, there is no specific indication provided to support the request for bone marrow aspirate for the 
approved surgery. There is a lack of large-volume, long-term peer-reviewed outcome studies to support the use 
of bone marrow aspirate for this enrollees medical condition as discussed above. There is no compelling 
rationale presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception. Therefore, the requested bone marrow aspirate in the setting of spinal fusion, in this case, is not 
medically reasonable or 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve bone marrow aspiration for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment to $15 for an office visit for an eye exam 
provided on June 2, 2022. 
 
You asked the Plan to reduce the copayment to $15 for the office visit for an eye exam. You say that an 
optometrist did the exam just like any eye exam. The Plan denied your request. The Plan says this cost sharing 
was charged correctly. Based on the additional information received, it was determined that you had an 
outpatient visit to treat or diagnose a condition of the eye. 
 
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 $45 
copayment for vision care for each Medicare-covered outpatient visit for services to diagnose and/or treat a 
disease or condition of the eye.  
 
You have been asked to pay a $45 copayment for the office visit for an eye exam. This service falls within the 
vision care 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 to $15 for an office visit for 
an eye exam provided on June 2, 2022.
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 is medically necessary. The Plan denied your 
request. The Plan says the IRF care is not medically necessary, and your needs can be met at a lower level of 
care such as a skilled nursing facility (SNF). 
 
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 you were admitted for surgical management of a bowel obstruction. The record shows your medical problems are stable, and there are no complex nursing or rehabilitation needs. You do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation 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 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for eyeglasses provided on  
January 10, 2022. 
 
You asked the Plan to pay an additional amount for the eyeglasses. The Plan denied your request. The Plan 
says the member has already been reimbursed the $115.00 per the 2022 benefit coverage. The member is 
responsible for any amount over $115.00. 
 
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  
 
 We looked at the file and the Plan's rules. The file shows that the Plan has paid the maximum eyewear benefit 
of $115.Therefore, we decided that the Plan does not have to pay an additional amount for eyeglasses provided 
on January 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that you need more incontinence supplies. 
The Plan denied your request. The Plan says incontinence supplies are not covered under your medical 
benefits.  The Plan says that you do have an supplemental $75 over-the-counter benefit under which coverage 
of certain adult diapers and bladder control pads are available.  Coverage under this benefit is limited to those 
items listed and only up to $75.  You are requesting items beyond this benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable. Your Plan does offer an over-the-counter benefit for 
certain incontinence supplies, but that is limited to $75.  You are requesting incontinence supplies beyond this 
benefit. 
 
While more incontinence supplies may be appropriate in this case, Medicare does not offer coverage of these 
items. Your over-the-counter benefit only covers listed items up to $75 per month.  We cannot require the Plan 
to provide benefits in excess of what is listed in your contract. Therefore, we decided that the Plan does not 
have to pre-approve incontinence supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite filling (D2391) provided on February 23, 2022.

You asked the Plan to pay for the filling. You say that the dental services were medically necessary. 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 September 20, 2021. The request for payment of the filling provided on February 23, 2022, was also within six (6) months of the initial filling (D2391). Therefore, we decided that the Plan does not have to pay for the resin-based composite filling (D2391) provided on February 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a microprocessor knee for a prosthetic leg.
You asked the Plan to pre-approve a microprocessor knee for a prosthetic leg. You say that this equipment is
medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the
correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for a microprocessor
knee for a prosthetic leg. The Maximus Physician Reviewer determined that the requested services are
considered medically reasonable and necessary in this case. The Plan requested a reopen and argues that a
microprocessor knee exceeds the enrollee's need. "Member has never used a K2 knee or a K3 mechanical knee.
No documentation of failure of mechanical K3 knee." The plan states that that there is no objective clinical
documentation to support the need for a microprocessor knee, or to show why a mechanical K3 knee cannot be
used for the initial prosthesis. The medical records show you underwent a left above knee amputation in
December 2021. You are currently without a prosthesis and use a wheelchair as his primary means of mobility.
You use a rolling walker for transfers. A fluid, pneumatic, or electronic/microprocessor knee (L5828, L5848,
L5856) is covered for beneficiaries whose functional level is 3 or above. The plan is correct in this case. The
clinical documentation in the case file does not support that the enrollee's functional level is 3 or above.
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 microprocessor knee for a prosthetic leg have not been met. Therefore, we
decided that the Plan does not have to pre-approve a microprocessor knee for a prosthetic leg.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that a LTACH admission is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for 
coverage of a LTACH admission. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee was admitted to the acute care hospital with bleeding and an 
infection from a groin ulcer requiring debridement, blood transfusion, wound care, and antibiotics. She had a 
high supratherapeutic international normalized ratio (INR) on warfarin and was switched to Eliquis. Recent 
notes describe the enrollee as requiring ongoing antibiotics and basic wound care but without formal plans for 
additional surgery. The enrollee appears to be more stable and improving and should only require short-term 
additional acute care hospital services that can safely be provided at the current facility until more stable and 
appropriate for a lower level of care.  The enrollee does not require services at the LTACH that are not already available at the current facility.  
There are no services at the LTACH that the enrollee requires that are not already available and covered at the 
current facility. Transfer to the LTACH is not medically necessary as it would not be clinically advantageous at 
this time. Completion of treatment at the current facility 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.