Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from November 17, 2023, 
forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from November 17, 2023, forward. You say that 
the services at issue were medically necessary. The Plan denied your request. The Plan says the services at 
issue were 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 
November 17, 2023, forward. Our reviewer says that you do not meet the criteria for treatment in an acute 
inpatient mental health treatment beyond the date in question of November 17, 2023, forward. Our physician 
reviewer found you did not require inpatient mental health treatment beyond November 17, 2023, as you were 
not a danger to yourself 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 your 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 November 17, 2023, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from November 17, 
2023, forward.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retainer crown - porcelain fused to noble metal (D6752) 
for teeth numbers 4, 6 and 8, and pontic - porcelain fused to noble metal (D242) for teeth numbers 5 and 7. 
 
You asked the Plan to pre-approve retainer crown - porcelain fused to noble metal (D6752) for teeth numbers 
4, 6 and 8, and pontic - porcelain fused to noble metal (D242) for teeth numbers 5 and 7. You say that you have 
attempted five times to get the services approved, but the Plan continues to deny for not meeting clinical 
criteria. You also say that you cannot get an answer as to why. The Plan denied your request. The Plan says the 
services did not meet the criteria for coverage. 
 
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. The Plan covers retainer 
crown - porcelain fused to noble metal (D6752) for teeth numbers 4, 6 and 8, and pontic - porcelain fused to 
noble metal (D242) for teeth numbers 5 and 7 when the services are medically necessary and reasonable.   
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 retainer crown - porcelain fused to 
noble metal (D6752) for teeth numbers 4, 6 and 8, and pontic - porcelain fused to noble metal (D242) for teeth 
numbers 5 and 7. Our reviewer says that the enrollee does not meet the criteria for the requested services. Our 
physician reviewer found the x-rays are poor quality and undiagnostic. Our physician reviewer also found that 
the requested services are not medically reasonable or necessary based on the information provided. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of retainer crown - porcelain fused to noble metal (D6752) for teeth numbers 4, 6 
and 8, and pontic - porcelain fused to noble metal (D242) for teeth numbers 5 and 7 have not been met. 
Therefore, we decided that the Plan does not have to pre-approve retainer crown - porcelain fused to noble 
metal (D6752) for teeth numbers 4, 6 and 8, and pontic - porcelain fused to noble metal (D242) for teeth 
numbers 5 and 7.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Sprint peripheral nerve stimulator (PNS). 
 
You asked the Plan to pre-approve Sprint PNS. You say that this is medically necessary for the enrollee. The 
Plan denied your request. The Plan says the enrollee does not meet criteria for this service. 
 
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 Sprint PNS. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this is considered experimental therapy and there are ongoing clinical trials for this technology. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Sprint PNS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Sprint peripheral nerve stimulator (PNS).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Ease Adjustable Base for your bed plus the Platinum 
Service. 
 
You asked the Plan to pay for the Ease Adjustable Base for your bed plus the Platinum Service. You say that 
the items should be covered. The Plan denied your request. The Plan says this was obtained through a provider 
that is not enrolled in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the Ease Adjustable Base for your bed 
plus the Platinum Service.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Negative Pressure Wound Therapy (NPWT) pump 
(E2402). 
 
You asked the Plan to pay for the NPWT. You say that this should be covered. The Plan denied your request. 
The Plan says the item is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that NPWT pumps (E2402) must be capable of 
accommodating more than one wound dressing set for multiple wounds on a beneficiary. Therefore, more than 
one E2402 billed per beneficiary for the same time period will be denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the NPWT have not been met. Therefore, we decided that the Plan does not have to pay for the 
Negative Pressure Wound Therapy (NPWT) pump (E2402).
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) provided 
on March 27, 2023, through April 13, 2023. 
 
You asked the Plan to pay for the fluid circulating cold pad with pump. You say that the item was medically 
necessary. The Plan denied your request. The Plan says the item was not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a fluid circulating cold pad with pump (E0218) 
will be denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the fluid circulating cold pad with pump have not been met. Therefore, we decided that the Plan 
does not have to pay for the fluid circulating cold pad with pump (E0218) provided on March 27, 2023, 
through April 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on July 31, 2023, billed with 
codes 87481, 87640, 87641, 87651, and 87653. 
 
You asked the Plan to pay for the genetic testing billed. You say that the services were medically necessary. 
The Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. The file shows that urinary tract infection panel testing was provided. We looked at the file and Medicare rules. 
This NGS panel was not billed with a single code as required. Based on this information, we decided that 
Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan 
does not have to pay for the genetic testing provided on July 31, 2023, billed with codes 87481, 87640, 87641, 
87651, and 87653.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee was to be discharged from the facility, 
but his condition changed, and he needed to be at the facility longer. The Plan denied your request. The Plan 
says it has been determined that the criteria for continued coverage of skilled nursing facility is no longer met. 
 
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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance transportation services provided to the
enrollee on September 26, 2021.

You asked the Plan to pay for the ambulance transportation services. You say that the enrollee was picked up
from their home and transported to the emergency department. The Plan denied your request. The Plan says
that the transport happened while the enrollee was inpatient. Maximus overturned the Plan's denial. The Plan
requested a reopening and stated that this cannot be covered because the enrollee was inpatient when
ambulance transportation services were provided. The Plan is correct in this case. Based on the medical records
and the facility claim, the enrollee was an inpatient on September 26, 2021, and was not picked up at a
residence as is stated on the claim. Medicare rules say that once a beneficiary is admitted to a hospital the
movement of the patient is considered "patient transportation" and is covered as an inpatient hospital service.
Based on this information, we decided that Medicare rules for coverage of the ambulance transportation
services have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance
transportation services provided to the enrollee on September 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a weight loss program. 
 
You asked the Plan to pay for a weight loss program. You say that the service should be covered. The Plan 
denied your request. The Plan says the maximum benefit for this service has been exhausted. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers gym benefits 
only The plan will reimburse members up to a maximum of $150 per calendar year towards program fees for 
weight loss programs.. 
 
The Plans rules for coverage of gym benefits have not been met because You have already reached the 
maximum benefit allowed for this service.. Therefore, we decided that the Plan does not have to pay for a 
weight loss program.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional neuropsychological testing. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says 
additional hours of testing are not medically necessary.  
 
The Plan must follow Medicare rules. Medicare rules say that psychological and neuropsychological testing is 
only covered under certain medical indications.  
 
The file shows that the Plan has agreed to pre-approve 10 hours of testing. The remaining 3 and a half hours 
remain denied. 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 additional services 
services. Our physician reviewer found that this testing is intended to diagnose and characterize the 
neurocognitive effects of medical disorders that impinge directly on or indirectly on the brain. The 
documentation does not show the reason for extra diagnostic time of neuropsychological testing. Therefore, the 
extra diagnostic time of neuropsychological testing is not considered reasonable or medically necessary for the 
treatment of this enrollees condition utilizing the information provided. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve additional neuropsychological testing.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prosthetic component L5981. 
 
You asked the Plan to pre-approve the requested item. You say that the item is required to absorb ground forces 
and reduce axial tension. The Plan denied your request. The Plan says the enrollee is not a level 3 ambulator.  
 
The Plan follows Medicare rules. Medicare rules say that lower limb prostheses are only covered under certain 
medical indications.  
 
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 requested item. Our physician 
reviewer found that the certified prosthetist-orthotist (CPO) states that the enrollee is a level 3 ambulator, but 
this is not corroborated by the treating medical provider records as per Medicare guidelines. The enrollee is 
ambulatory but has weakness/instability in the right lower extremity, which needs stabilization from a semi-
rigid orthosis. He was given a post-operative shoe for the right leg. The enrollee notes mild fatigue and fair 
physical health. The enrollee can carry on everyday physical activities like walking, stair climbing, carrying 
groceries, or moving a chair "a little". The prosthetist is the vendor. The physician assistant documentation 
does not discuss the enrollees ambulatory level or support the prosthetist's claims of the enrollees need for the 
requested item. Therefore, the request is not 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 requested item have not been met. Therefore, we decided that the Plan does 
not have to pre-approve prosthetic component L5981.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Koya non-pneumatic compression garment. 
 
You asked the Plan to pre-approve the requested device. You say that the system moves excess fluid for 
processing by the body. The Plan denied your request. The Plan says there is lack of medical literature that the 
requested device is more efficacious than standard pneumatic compression devices. 
 
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 requested device. Our physician 
reviewer found that the enrollee has attempted to alleviate their lower extremity edema/lymphedema with four 
weeks of compression, exercise, and elevation. The medical documentation does not make clear what form of 
compression was utilized other than possibly Unna boots. It is unclear as to how many Unna boots have been 
applied to date.  The medical documentation does not support that this enrollee has tried more conventional pneumatic 
compression devices.  Medical literature does not support that the Kona Dayspring non- pneumatic Active 
Dynamic compression garment is indicated over standard compression devices. Therefore, the requested 
compression garment for this enrollees lower extremity of edema 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 requested device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Koya non-pneumatic compression garment.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for a low dose lung cancer screening computed tomography (CT) scan 
received on June 26, 2023. 
 
You asked the Plan to pay for the CT scan. You say that the services were medically necessary. The Plan 
denied your request. The Plan says that the information between the claim and the referral do not match. 
 
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. We find that there is no reason given to support a denial. Therefore, we decided 
that the Plan has to pay for a low dose lung cancer screening computed tomography (CT) scan received on June 
26, 2023.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the cervical 
spine. 
 
You asked the Plan to pre-approve the MRI. You say that you are in pain even with pain medications, after an 
x-ray your physician is requesting an MRI. The Plan denied your request. The Plan says the is no indication of 
any treatment tried and failed for pain. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the MRI. Our reviewer says that the 
MRI is not medically necessary. Our physician reviewer found the documentation provided does not show any 
red flag warning. You have not had a trial of conservative therapy treatment such as physical therapy. You do 
not meet the criteria for approval 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 the MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a magnetic resonance imaging (MRI) of the cervical spine.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a power scooter provided from March 13, 2023, to May 24, 
2023. 
 
You asked the Plan to pay for power scooter. You say that you needed this scooter. The Plan denied your 
request. The Plan says this provider is not certified by Medicare and is not eligible for payment. 
 
The Plan must follow Medicare rules. Medicare rules say that to receive payment for covered equipment, the 
supplier must be enrolled in Medicare.  
 
We looked at the file and Medicare rules. You purchased this equipment from a provider that is not enrolled in 
the Medicare program; therefore, the provider is not eligible for payment. Based on this information, we 
decided that Medicare rules for coverage of power scooter have not been met. Therefore, we decided that the 
Plan does not have to pay for a power scooter provided from March 13, 2023, to May 24, 2023.