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

 
We decided that the Plan has to pay for the electrical stimulation supplies billed for date of service October 9, 
2022. 
 
You asked the Plan to pay for the services provided. You say that the billed code is an accepted procedure 
code. The Plan denied your request. The Plan says that a valid proof of delivery was not submitted. 
 
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. 
 
We looked at the file and the rules. The records submitted include what appears to be a valid proof of delivery. 
The tracking number on the packing slip is the same on the delivery ticket. The Plan has not provided evidence 
that the delivery confirmation was digitally altered, or provided any indication that the delivery documentation 
is fraudulent. The Plan has not made reasonable and diligent efforts to gather and forward to us information 
regarding their decision to deny your request.  Therefore, we decided that the Plan has to pay for the electrical 
stimulation supplies billed for date of service October 9, 2022.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are requesting reconsideration 
stating LTACH is the safest level of care based on the enrollee's current complex medical recovery needs. The 
Plan denied your request. The Plan says criteria for admission to the LTACH have not been met. 
 
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 the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. The Plan has approved ongoing care in the current acute 
care setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting reconsideration for the denial of 
an IRF admission. The Plan denied your request. The Plan says the enrollee does not meet medical necessity 
guidelines for admission to an IRF. 
 
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 the clinical documentation does not specify any active medical comorbidities or 
complex functional impairments. Thus, the complexity of the enrollee's documented nursing, medical and 
rehabilitation needs would not be expected to require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation 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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on November 21, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. 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 March 14, 2022, and July 
18, 2022. Therefore, we decided that the Plan does not have to pay for the dental services on November 21, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64628, 64629). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the Intracept procedure meets all the 
above criterion used to evaluate whether a device is investigational. The Plan denied your request. The Plan 
says the physical exam and radiologic studies show additional significant pathologies that are unlikely to 
benefit from the Intracept procedure 
 
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 enrollee has a diagnosis of vertebrogenic low back pain. Disabling symptoms 
persist following medication management, physical therapy, and lumbar epidural steroid injections. Magnetic 
resonance imaging (MRI) completed on November 29, 2022, demonstrated multilevel Modic degenerative 
changes, as well as bilateral neural foraminal stenosis and moderate spinal canal stenosis. The enrollee has 
facet degenerative joint disease and spinal stenosis that could explain the source of the enrollees 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 the Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure (64628, 64629).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve electrical stimulation (G0283), craniofacial and 
maxillofacial procedure (21299) and unspecified temporomandibular therapy (D7899) for TMJ treatment. 
 
You asked the Plan to pre-approve TMJ treatment. You say that you are requesting treatment that will consist 
of a universal lower orthotic. You say the orthotic is fabricated using transcutaneous electro neural stimulation, 
myography, sonography and jaw tracking technology. The Plan denied your request. The Plan says there is no 
clinical documentation to support the medical necessity of the unlisted codes (21299 and D7899), and electrical 
stimulation (G0283) is not listed as part of the treatment for TMJ. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers treatment for TMJ syndrome only 
when the condition or symptom is medical in nature. The treatment must also be medically reasonable and 
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 temporomandibular joint (TMJ) 
treatment. Our reviewer says that the service is not medically necessary. Our physician reviewer found the 
treatment is focused on a medical condition since it is directed to the joint itself. However, the elaborate 
tracings and neuromuscular treatment to obtain the tracing is not shown to be medically necessary. The 
treatment modalities indicated by non-specified treatment codes would not be considered medically appropriate 
as they have not been reliably shown to produce a reliable resolution of TMJ disorders. These procedures are 
experimental in nature. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of temporomandibular joint (TMJ) treatment have not been met. Therefore, we 
decided that the Plan does not have to pre-approve electrical stimulation (G0283), craniofacial and 
maxillofacial procedure (21299) and unspecified temporomandibular therapy (D7899) for TMJ treatment.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung 
cancer screening. 
 
You asked the Plan to pre-approve the requested LDCT scan. You say that you are requesting an expedited 
appeal for the denial of a LDCT scan based on medical necessity. The Plan denied your request. The Plan 
says given that the age limit is exceeded, you do not meet criteria of medical necessity. 
 The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung 
cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.  
 
We reviewed the file and the Medicare rules. We find that according to Medicare guidelines, the age limit for 
lung cancer screening is 77 years old. The record shows that you are 78 years old and Medicare guidelines 
indicate that this test is no longer appropriate over the age of 77 years old. Therefore, we decided that the Plan 
does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endoscopy with tissue ablation and reconstruction of 
atria without cardiopulmonary bypass. 
 
You asked the Plan to pre-approve endoscopy with tissue ablation and reconstruction of atria without 
cardiopulmonary bypass. You say that you disagree with the Plan's 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 endoscopy with tissue ablation and 
reconstruction of atria without cardiopulmonary bypass. Our reviewer says that the requested items/services are 
not considered medically reasonable and necessary in this case. Our physician reviewer found you have atrial 
fibrillation. A study demonstrated the superiority of this hybrid approach combining epicardial and endocardial ablation compared with an endocardial catheter ablation procedure alone.  However, supportive, randomized, 
longer-term clinical studies are awaited, including direct comparisons of hybrid ablation procedures with 
alternative treatment options. As a result, at this time, authorization for the performance of a convergent hybrid 
ablation procedure would not be considered appropriate and reasonable in your clinical management. 
Therefore, you do not meet criteria for the requested 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 endoscopy with tissue ablation and reconstruction of atria without 
cardiopulmonary bypass have not been met. Therefore, we decided that the Plan does not have to pre-approve 
endoscopy with tissue ablation and reconstruction of atria without cardiopulmonary bypass.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve teeth extractions and dentures to be covered under the
enrollee's medical benefit.
You asked the Plan to pre-approve teeth extractions and dentures to be covered under the enrollee's medical
benefit. You say that the dental procedures are necessary. The Plan denied your request. The Plan says that the
requested dental services are not covered under the enrollee's medical benefit.
The Plan follows Medicare rules. Medicare rules say that Medicare generally does not cover dental services.
Therefore, we decided that the Plan does not have to pre-approve teeth extractions and dentures to be covered
under the enrollee's medical benefit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fluid circulating cold pad with pump (E0218), and 
pneumatic compression device (PCD) (E0676) provided on October 27, 2021. 
 
You asked the Plan to pay for the cold pad and PCD. You say that you feel these items should be covered. You 
say that you feel that you had met your deductible and copayment obligations. You also say that it is your 
belief that the items were already paid for by your plan. The Plan denied your request. The Plan says the items 
are not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that a fluid circulating cold pad with pump will be 
denied as not reasonable and necessary. Additionally, items used for a preventative service or function are 
excluded from Medicare coverage.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the durable medical equipment have not been met. Additionally, the record shows that you signed a 
notice of noncoverage agreeing that you would be responsible for payment. Therefore, we decided that the Plan 
does not have to pay for the fluid circulating cold pad with pump (E0218), and pneumatic compression device 
(PCD) (E0676) provided on October 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compressor, segmental home model without calibrated gradient pressure (E0651) provided to the enrollee on February 1, 2022.

You asked the Plan to pay for this equipment. You say that this claim should be paid. The Plan denied your request. The Plan says the Medicare coverage criteria were not met. Maximus overturned the Plans denial for insufficient information in the case file. The Plan requested a reopen and noted that 5 years of reasonable useful lifetime had not passed since the enrollee's receipt a pneumatic compression device billed under the same
codes, E0651-NU and E0667-NU-RT and LT. The claim history shows the enrollee was billed for a pneumatic compression device and two segmental appliances on June 21, 2017. The enrollee would not have been eligible to receive new equipment covered by Medicare until July 1, 2022 (which is when the five years would have officially expired (June 21, 2022 and the beginning of a new billing cycle which would be July 1, 2022). This equipment was provided in February, prior to the five-year expiration. 

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare only replaces equipment every 5 years. This equipment was provided 5 months prior to the expiration of 5 years from the previous purchase. 
Medicare rules for coverage of this equipment have not been met. Therefore, we decided that the Plan does not have to pay for a pneumatic compressor, segmental home model without calibrated gradient pressure (E0651) provided to the enrollee on February 1, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient care provided to the enrollee from July 11, 2022, to July 18, 2022.
You asked the Plan to pay for July 11, 2022, to July 18, 2022. You say that these services should be paid by the Plan. The Plan denied your request. The Plan says additional records were requested regarding the dates of service denied showing necessity. Maximus overturned the Plans denial for insufficient denial information in the case file. The Plan requested a reopen and provided additional documentation to show several requests were made by the Plan for records or a peer review to establish the necessity for the denied days.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.
The records provided contain insufficient information to determine if Medicare rules for coverage of inpatient care from July 11, 2022, to July 18, 2022 were met. Therefore, we decided that the Plan does not have to pay for inpatient care provided to the enrollee from July 1, 2022, to July 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block. 
 
You asked the Plan to pre-approve a genicular nerve block. You say that it is very hard to stand and walk. The 
Plan denied your request. The Plan says the clinical value and effectiveness of a genicular nerve block in the 
setting of knee pain after a total knee replacement. 
 
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 a genicular nerve block. Our reviewer 
says that a genicular nerve block is not considered medically reasonable and necessary in this case. Our 
physician reviewer found detailed documentation is not evident regarding a trial and failure of recent, 
reasonable, comprehensive less invasive conservative care measures for the knees. Additionally, there is 
limited published, large-scale, long-term peer-reviewed literature that shows this request to be an effective and/or safe treatment for the noted pathology. No compelling rationale is presented, or extenuating 
circumstances noted to support the medical necessity of this request as an exception. 
 
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 genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a genicular nerve block.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Metformin. 
 
You asked the Plan to pre-approve Metformin. You say that the enrollee needs this drug. The Plan denied your 
request. The Plan says the requested drug is considered self-administered. The Plan says self-administered 
drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not 
covered under Medicare Part B. 
 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 Metformin.  
 
Benefits for Metformin 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zioptan. 
 
You asked the Plan to pre-approve Zioptan. You say that you would like long term insurance coverage to be 
allowed for Zioptan, to assist in preserving the enrollee's remaining vision and prevent additional vision loss, 
which cannot be regained with any ophthalmic treatments, procedures, or surgeries. The Plan denied your 
request. The Plan says Zioptan is a self-administered drug, and does not fall under Part B 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 Zioptan.  
 
Benefits for Zioptan 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation feature (E2300) and push handles 
for wheelchair (K0108x2). 
 
 
 You asked the Plan to pre-approve wheelchair accessories. You say that you disagree with the denial and 
request reconsideration. The Plan denied your request. The Plan says the push handles and power seat elevation 
feature are non-covered because they are not primarily medical in nature. Of additional note, the push handles 
are primary for the convenience of the person caring for the enrollee, and as such are not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The items at issue in this appeal do not serve a purpose that is primarily medical in nature. These items are 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a power seat elevation feature (E2300) and push handles for 
wheelchair (K0108x2).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting an expedited reconsideration for 
the denial of an IRF admission. The Plan denied your request. The Plan says the enrollee does not meet the 
Medicare coverage criteria for an IRF admission. 
 
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 the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of 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 IRF admission and services.