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

 
We decided that the Plan does not have to pre-approve CardioMEMS. 
 
You asked the Plan to pre-approve CardioMEMS. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested services 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 CardioMEMS. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has recurrent congestive heart failure (CHF). The clinical study on which Food and 
Drug Administratio (FDA) approval was based showed improved clinical outcomes and decreased 
hospitalizations in patients in whom the CardioMEMS system was implanted, reflecting an enrollee population 
with preserved ejection fraction and was somewhat limited in scope. Subsequent follow-up studies remain 
encouraging and suggest an improvement in heart failure symptoms with the use of the device. In addition, 
published expert opinion in the cardiology literature is supportive of the clinical usefulness of CardioMEMS. 
Nonetheless, there remains a dearth of randomized, blinded clinical studies examining long-term clinical 
outcomes establishing the value of CardioMEMS in enrollee management. As a result, at this time the CardioMEMS system would not be considered medically appropriate and necessary in this enrollees 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 CardioMEMS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve CardioMEMS.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care visit provided on January 17, 
2022. 
 
You asked the Plan to waive the copayment for urgent care visit. You say that you were not advised that you 
needed a referral. The Plan denied your request. The Plan says the copayment amount you are being charged is 
correct. 
 
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 $30 
copayment for each urgent care visit.  
 
You have been asked to pay $30 copayment for urgent care visit. Urgent care visit falls within the Urgently 
Needed 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 an urgent care visit 
provided on January 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the special anesthesia service (99100) provided on February 
17, 2022. 
 
You asked the Plan to pay for the special anesthesia service (99100). You say that the attached corrected 
medical records should be reviewed. The Plan denied your request. The Plan says procedure code 01402 has 
been overturned and procedure code 99100 remains denied as bundled services are not eligible for separate 
payment.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99100 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the special anesthesia service (99100) have not been met. Therefore, we decided that the Plan does not have 
to pay for the special anesthesia service (99100) provided on February 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve extraction, erupted tooth requiring removal of bone 
and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210) and 
comprehensive oral evaluation - new or established patient (D0150) to be provided by an oral surgeon. 
 
You asked the Plan to pre-approve an extraction and comprehensive oral exam. You say that your cardiologist 
recommends having an oral surgeon perform these services. The Plan denied your request. The Plan says these 
services are not covered when performed by an oral surgeon. 
 
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. The Plan covers an extraction 
and comprehensive oral exam when the services are performed by a participating general dentist. 
 
We looked at the file and Medicare rules. In this case the services are requested to be performed by an oral 
surgeon. Based on this information, we decided that the Plan's rules for coverage of an extraction and 
comprehensive oral exam have not been met. Therefore, we decided that the Plan does not have to pre-approve 
extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of 
mucoperiosteal flap if indicated (D7210) and comprehensive oral evaluation - new or established patient 
(D0150) to be provided by an oral surgeon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal of torus mandibularis (D7473). 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says removal of torus mandibularis (D7473) 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 the 
removal of torus mandibularis (D7473).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 4 additional physical therapy visits. 
 
You asked the Plan to pre-approve physical therapy. You say that you are appealing this denial. The Plan 
denied your request. The Plan says the denial of authorization for this service is correct because these 
additional visits are not medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 physical therapy. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found there is no recent re-evaluation indicating progress with regards to the 
enrollee's strength and function as they relate to mobility and performing activities of daily living. Additional 
visits are not 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 4 additional physical therapy visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 4 additional physical therapy visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from July 19, 2022, forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from July 19, 2022, forward. You say that the 
services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are 
not medically necessary. 
 The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care from July 19, 
2022, forward. Our reviewer says that the enrollee does not meet the criteria for acute inpatient mental health 
treatment beyond the date in question of July 19, 2022, forward. Our physician reviewer found the enrollee did 
not require inpatient mental health treatment beyond July 19, 2022, as she was not a danger to herself or others 
and did not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was 
taking place beyond the date in question. It did not appear that the services for the dates in question were 
reasonably expected or medically necessary to improve the enrollees condition or for the purpose of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from July 19, 2022, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from July 19, 2022, 
forward.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) services. 
 
You asked the Plan to pre-approve RFA services. You say that the records provided support the need for the 
injection services in dispute. The Plan denied your request. The Plan says the records do not show that the 
enrollee has had two medical branch block injections that show an 80% improvement in pain. 
 
The Plan follows Medicare rules. Medicare rules say that RFA services are covered for certain clinical 
indications and when specific coverage criteria have 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 RFA services. Our reviewer says that 
the criteria for coverage have not been met. Our physician reviewer found the enrollee underwent right L2-L3, 
L3-L4, L4-L5, and L5-S1 facet joint injections on May 31, 2022, which provided 40% relief for a few days. 
The review has determined that the criteria for coverage have not been met because the records show that the 
enrollee did not have 2 MBBs that provided an 80% improvement in pain. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of RFA services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve radiofrequency ablation (RFA) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the extractions, erupted tooth requiring removal of bone 
and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210) and 
comprehensive oral evaluation - new or established patient (D0150) to be provided by an oral surgeon. 
 
You asked the Plan to pre-approve the extractions and comprehensive oral exam. You say that you would like 
the Plan to cover at least one extraction. The Plan denied your request. The Plan says these services are not 
covered when provided by an oral surgeon. 
 
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. The Plan covers the 
extractions and comprehensive oral exam when the services are performed by a participating general dentist.  
 
We looked at the file and Medicare rules. In this case the services are requested to be provided by an oral 
surgeon. Based on this information, we decided that the Plan's rules for coverage of the extractions and 
comprehensive oral exam have not been met. Therefore, we decided that the Plan does not have to pre-approve 
the extractions, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of 
mucoperiosteal flap if indicated (D7210) and comprehensive oral evaluation - new or established patient 
(D0150) to be provided by an oral surgeon.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care associated with an elective 
surgery. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that you need an inpatient admission. The 
Plan denied your request. The Plan says the inpatient admission is not medically necessary, and the procedure 
is not on the Medicare Inpatient Only list. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.   
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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the knee replacement may be safely performed as a 48-hour observational stay. An 
inpatient hospital admission does not appear to be medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care associated with an elective surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay additional reimbursement for physician services provided on
August 20, 2021, and August 27, 2021.
You asked the Plan to pay more for these services. You say that you believe the Plan owes you additional
reimbursement. The Plan denied your request. The Plan says this service does require cost share. Maximus
overturned the Plans denial because the contractual copayment information had not been provided in the case
file. The Plan requested a reopen and provided the required contract documentation.
The Plan is correct in this case. 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 $25 for each acupuncture visit.
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 pay additional reimbursement for physician services provided on August 20, 2021, and August
27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prophylaxis (D1110) provided on March 8, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
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 item or service was exhausted on date of service October 6, 2021. 
Therefore, we decided that the Plan does not have to pay for prophylaxis (D1110) provided on March 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care visit provided on September 
10, 2021. 
 
You asked the Plan to waive the copayment for urgent care visit. You say that the only reason you went to this 
provider was for a COVID-19 test. The Plan denied your request. The Plan says the copayment amount you are 
being charged is correct. 
 
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 $45 
copayment for urgent care visit.  
 
You have been asked to pay $45 copayment for urgent care visit. Urgent care visit falls within the Urgently 
Needed 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 an urgent care visit 
provided on September 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Knee orthosis (L1851). 
 
You asked the Plan to pre-approve the orthosis. You say that  The Plan denied your request. The Plan says the 
request is not medically necessary because the records do not show you have had a recent injury or or surgery 
of the knees nor objective evidence of knee instability. 
 
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 orthosis. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found in this case, the record indicates that the enrollee has knee pain from osteoarthritis.  The record 
does not indicate knee instability by examination or the presence of recent injury or surgery. The elements of 
the coverage criteria are not satisfied.  The requested service is not 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 orthosis have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Knee orthosis (L1851).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lightweight portable oxygen concentrator. 
 
You asked the Plan to pre-approve a lightweight portable oxygen concentrator. You say that you cannot leave 
the house with the provided giant oxygen tanks. The Plan denied your request. The Plan says rules for coverage 
for durable medical equipment have not been met. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a lightweight portable oxygen concentrator.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve skilled nursing facility (SNF) services. You say that you would like to 
request reconsideration stating that the member is showing progress and needs more time to be 
independent. The member just started walking and needs more time to regain strength. The Plan denied your 
request. The Plan says the services you are requesting do not meet the requirements for approval. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 skilled nursing facility (SNF) services. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found they agree with the 
denial of skilled nursing facility (SNF) 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 skilled nursing facility (SNF) services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. The Plan denied your request. The Plan says you do not have 
a brace or diabetes. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
The records do not show that you suffer from diabetic foot disease or wear a leg brace. Although orthotics may 
be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. 
Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a therapeutic CGM. You say that this item is medically reasonable and 
necessary. The Plan denied your request. The Plan says the criteria for coverage 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 the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
therapeutic continuous glucose monitor (CGM).