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

We decided that the Plan does not have to provide coverage for Feraheme for the enrollee.
You asked the Plan to provide coverage for Feraheme. You say that this drug 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 Feraheme
(Ferumoxytol). The Maximus Physician Reviewer determined that the requested use of Feraheme is FDAapproved
for the enrollee's diagnosis. The Plan notes that their coverage criteria require that an enrollee have a
diagnosis of iron deficiency anemia with a hemoglobin less than 12 g/dL in women, and iron studies such as
TSAT of less than 20% and/or ferritin of less than 30 ug/L and have tried and failed or are unable to take oral
iron or have chronic kidney disease. The medical records show the enrollee is an 81-year-old woman with a
diagnosis of iron deficiency who is on oral ferrous sulfate. On July 13, 2021, the enrollee's hemoglobin was
11.7 g/dL. On January 31, 2022, the enrollee was evaluated by specialisits. The plan
included repeat laboratory studies with CBC, CMP, iron studies, and vitamin B12. The case file does not
contain the results of that laboratory testing. The Plan is correct in this case. Without the results of recent
laboratory testing, it could not be determined that Feraheme was medically reasonable and necessary for this
enrollee.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Feraheme have not been met. Therefore, we decided that the Plan does not have
to provide coverage for Feraheme for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an unspecified adjunctive procedure (D9999) provided a 
participating provider. 
 
You asked the Plan to pre-approve an unspecified adjunctive procedure. You say that you had to switch your 
diet, and you have lost a lot of weight due to your soft food diet. The Plan denied your request. The Plan says 
the requested dental work 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
unspecified adjunctive procedure (D9999) provided by a participating provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the commode chair, mobile or stationary, with fixed arms 
(E0163). 
 
You asked the Plan to pay for the commode chair. You say that the enrollee has difficulty with transfers, 
especially during the night. To decrease the possibility of falls, the home bedside commode chair is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet the criteria for the requested 
service. 
 
The Plan must follow Medicare rules. The rules say that a commode chair is covered only for enrollees who are 
confined to a bed or room. 
 
The file does not show that you are confined to a bed or room as defined by Medicare rules. Therefore, we 
decided that the Plan does not have to pay for the commode chair, mobile or stationary, with fixed arms 
(E0163).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of the Superion interspinous spacer. 
 
You asked the Plan to pre-approve the Superion procedure. You say that this is a medically appropriate 
treatment for the enrollee's condition. The Plan denied your request. The Plan says the requested procedure 
remains experimental at this time. 
 
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 Superion procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found current evidence-based medical guideline and peer reviewed literature do not fully 
support the spinal decompression device procedure over the gold standard of lumbar laminectomy. There is a 
lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for this 
enrollees medical condition.  
 
Food & Drug Administration (FDA) indications include implantation of the Superion device at one or two 
adjacent lumbar levels in patients with moderate spinal stenosis in whom operative treatment is indicated at no more than two levels, from L1 to L5. This enrollee has multiple degrees of spinal stenosis, many not at FDA 
indicated levels of moderate spinal stenosis (including the planned level of implantation at L3-4 and L4-5 
levels). FDA contraindications include spinal instability, scoliosis, obesity, and osteoporosis, and have not been 
adequately addressed in the medical records. There is imaging evidence of listhesis of L4 over L5 with no 
discussion of spinal instability on flexion/extension films. There is imaging evidence of moderate levoscoliosis 
with no documentation of the Cobb angle. There is no discussion indicating that a bone density scan has 
demonstrated the lack of significant osteoporosis in this patient. The 4/12/21 x-rays of the lumbar spine have 
impressions of osteopenia. 
 
There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity 
of this request as an exception. Therefore, the request for Vertiflex Superion interspinous device at L3-4 and 
L4-5 levels 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 Superion procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve placement of the Superion interspinous spacer.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cardiovascular panel (81286, 81413, 81414, 81442, 81161, 
81479) provided on November 19, 2021, 
 You asked the Plan to pay for a cardiovascular panel. You say that this is supported in the records. The Plan 
denied your request. The Plan says this was not ordered. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular 
(CV) risk assessment panels, except the basic lipid panel, for symptomatic and asymptomatic patients. 
 
We looked at the file and Medicare rules. The services at issue are a CV risk assessment panel and are not 
covered. Based on this information, we decided that Medicare rules for coverage of a cardiovascular panel have 
not been met. Therefore, we decided that the Plan does not have to pay for a cardiovascular panel (81286, 
81413, 81414, 81442, 81161, 81479) provided on November 19, 2021,
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve electronic connection between wheelchair controller and
two or more power seating system motors, including all related electronics, indicator feature, mechanical
function selection switch, and fixed mounting hardware (CPT code E2311), expandable controller, including
all related electronics and mounting hardware, upgrade provided at initial issue (CPT code E2377) and harness
for upgrade to expandable controller, including all fasteners, connectors and mounting hardware (CPT code
E2313).
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your
request. The Plan says the DME is not necessary.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the DME have not been met. The upgraded electronics (expandable
controller, harness and electronic connector to 2 power options) are not medically necessary. They are
necessary when there is a medical need to control power options though the joystick. The notes do not show a
medical need to control the power options through the joystick. The power options can be controlled using their
own switches. These switches can be made any size without asking for a separate request. They can be made
from any material without asking for a separate request. All of this can be done without the need to use the
joystick to control the power features. Therefore, we decided that the Plan does not have to pre-approve
electronic connection between wheelchair controller and two or more power seating system motors, including
all related electronics, indicator feature, mechanical function selection switch, and fixed mounting hardware
(CPT code E2311), expandable controller, including all related electronics and mounting hardware, upgrade
provided at initial issue (CPT code E2377) and harness for upgrade to expandable controller, including all
fasteners, connectors and mounting hardware (CPT code E2313).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve small intestinal bacterial overgrowth (SIBO) breath test 
(91065). 
 
You asked the Plan to pre-approve the SIBO breath test. You say that please review for reconsideration to 
overturn the pre-determination. The Plan denied your request. The Plan says this service is not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the SIBO breath test have not been met. Therefore, we decided that the Plan does not have to pre-
approve small intestinal bacterial overgrowth (SIBO) breath test (91065).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve comprehensive orthodontic treatment of the adult 
dentition (D8090). 
 
You asked the Plan to pre-approve the comprehensive orthodontic treatment of the adult dentition. You say that 
you need this treatment to align your teeth so that you are eligible for a partial bridge. The Plan denied your 
request. The Plan says this service is not covered under your benefit package. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
comprehensive orthodontic treatment of the adult dentition (D8090).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve dental services provided by a participating provider. 
 
You asked the Plan to pre-approve dental services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that medically necessity has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has failed to provide dental x-rays that were legible. Therefore, we 
decided that the Plan has to pre-approve dental services provided by a participating provider.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on  
January 19, 2022. 
 
You asked the Plan to waive the copayment for ambulance services. The Plan denied your request. The Plan 
says the claim processed correctly. 
 
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 $290 
copayment for Ambulance Services.  
 
You have been asked to pay a $290 copayment for ambulance services. The ambulance services falls within the 
Ambulance 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 ambulance services  
provided on January 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Freestyle Libre 2 sensor kit. 
 
You asked the Plan to pre-approve the Freestyle Libre. You say that the enrollee would benefit from a Freestyle 
Libre to help with frequent blood sugar checks at a minimum of twice daily to monitor and prevent hyper and 
hypoglycemia and help with safety leading to improved longevity. The Plan denied your request. The Plan says 
the enrollee does not meet the Medicare criteria. 
 
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 perform blood glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the Freestyle Libre have not been met. Therefore, 
we decided that the Plan does not have to pre-approve the Freestyle Libre 2 sensor kit.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on July 29, 2021, and
billed under codes 85027, 80053 and 85025.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says while a portion of this claim was paid, code 85027 cannot be paid as billed. Maximus
partially overturned the Plans denial stating proof of payment for codes 80053 and 85025 had not been
provided. The Plan requested a reopen and provided documentation of payment.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. Providers must report services with the appropriate codes. The file shows that CPT
code 85027 was billed with code 85025. The claim information does not show that CPT code 85027 was billed
with a modifier suitable for payment. Therefore, we decided that the Plan does not have to pay for procedure
code 85027 provided on July 29, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 18 occupational therapy (OT) visits. 
 
You asked the Plan to pre-approve an additional 18 OT visits. You say that the requested services 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 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 an additional 18 OT visits. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of your condition. Our physician reviewer found you have previously been treated with outpatient therapies and 
should be independent with a home exercise program. There is no documentation of a recent injury or decline 
in function. The additional therapy services are not an appropriate duration and frequency for treatment of your 
medical condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an additional 18 OT visits have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an additional 18 occupational therapy (OT) visits.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray (71045) provided January 14, 2022. 
 
You asked the Plan to pay for the x-ray. You say that the services were medically necessary. The Plan denied 
your request. The Plan says the number of units billed are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
We find that 2 units of CPT code 71045 are not supported in the medical record. The medical record only 
supports 1 unit of CPT code 71045. Based on this information, we decided that Medicare rules for coverage of 
the x-ray have not been met. Therefore, we decided that the Plan does not have to pay for an x-ray (71045) 
provided January 14, 2022.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Pregabalin 75MG capsule (CPT code J8499).

You asked the Plan to pre-approve the medication. You say that the enrollee has nerve pain in their legs. The Plan denied your request. The Plan says Pregabalin 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 Pregabalin 75MG capsule (CPT code J8499). 

Benefits for the medication 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vivigen allograft. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the Vivigen allograft is considered 
experimental in spine surgery. The iliac crest is the gold standard. The Vivigen is therefore not reasonable or 
medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Vivigen allograft.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for Prolia for the enrollee.
You asked the Plan to provide coverage for Prolia. You say that Prolia is medically necessary. The Plan denied
your request. The Plan says the required step therapy criteria are not met. Maximus overturned the Plans denial.
The Plan requested a reopen and provided additional information.
Our Physician reviewer looked at the case file and the medical records. At issue is whether Prolia for the
enrollee is a covered service under Medicare rules. Medicare rules also allow the plan to use step therapy. This
is the process of beginning drug therapy for a medical condition with "preferred" (or more cost-effective) onformulary
drug alternative(s) and progressing to other drug therapies only as necessary. A plan must grant an
exception to its step therapy rules if it determines that the requested drug is medically necessary, consistent
with the prescriber's statement. The statement must show that the step therapy drugs have been ineffective in
treating the enrollee; or are likely to be ineffective or adversely affect the drug's effectiveness or patient
compliance; or are likely to cause an adverse reaction or other harm to the enrollee. The Plan requires a trial of
an oral bisphosphonate drug (e.g., Alendronate, Ibandronate, Risedronate) and zoledronic acid before they will
approve the requested drug. In this case, the record indicates that the enrollee has age related osteoporosis with
high risk of osteoporotic fracture. The requested medication is a new start. The medical records do not
indicate that the enrollee has tried and failed the plan's preferred step one alternative. The provided record does
not indicate the degree of enrollee's kidney disease. The record does not credibly indicate that the enrollee has a
contraindication to or would have an adverse effect from the plan's preferred step one alternative. The elements
of the coverage criteria are not satisfied.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to
provide coverage for Prolia for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a root canal obstruction on tooth #28 (D3331), surgical 
procedure on tooth #28 (D3910), therapeutic parenteral drugs (D9610, D9612). 
 
You asked the Plan to pre-approve an obstruction, surgical procedure, and parenteral drugs. You say that this is 
emergency treatment. The Plan denied your request. The Plan says these services are 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 pre-approve a 
root canal obstruction on tooth #28 (D3331), surgical procedure on tooth #28 (D3910), therapeutic parenteral 
drugs (D9610, D9612).