Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the office visit (99203) provided on February 7, 2023. 
 
You asked the Plan to pay for the outpatient service. You say that this should be covered. You also say that the 
provider is listed as in-network on the Plan's website. The Plan denied your request. The Plan says that the cost 
share was applied correctly. 
 
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. Medicare rules also say that a contract provider is an agent of the plan. Services and referrals given 
by a contract provider are considered approved by the plan unless notice is provided that the services will not 
be covered. The Plan follows these rules. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan did not provide any medical records or evidence of having 
made reasonable attempts to obtain medical records. The Plan also did not address the enrollees specific 
statement that they were referred to the servicing provider by an in-network provider. If the enrollee was 
referred for the services in dispute by a contracted provider, under Medicare rules this means the services are 
considered approved by the Plan. The Plan has not provided us with the information necessary to make a 
decision regarding its application of an out-of-network deductible. In addition, we confirmed with the Plan that 
the enrollee was seen at the Neptune location, and we verified on the Plans website that this provider is 
considered participating at this location. Therefore, we decided that the Plan has to pay for the office visit 
(99203) provided on February 7, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve deep sedation/general anesthesia first 15 minutes 
(D9222), and deep sedation/general anesthesia  each subsequent 15-minute increment (D9223 x3). 
 
You asked the Plan to pre-approve anesthesia . You say that you need the teeth taken out due to being a danger 
to your heart. The Plan denied your request. The Plan says this is not a covered service. 
 
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 deep 
sedation/general anesthesia first 15 minutes (D9222), and deep sedation/general anesthesia  each subsequent 15-minute increment (D9223 x3).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xolair (J2357). 
 
You asked the Plan to pre-approve the medication. You say that this is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says the medication is not covered as a medical benefit 
under the Plan. 
 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 Xolair (J2357).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Austedo. 
 
You asked the Plan to pre-approve Austedo. The Plan denied your request. The Plan says that self-administered 
drugs do not fall under Medicare 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 Austedo.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pulmonary rehabilitation services. 
 
You asked the Plan to pre-approve pulmonary rehabilitation services. You say that you feel this should be 
covered despite not having a diagnosis of chronic obstructive pulmonary disease (COPD). You also say that your pulmonary doctor recommended this to enhance your breathing. The Plan denied your request. The Plan 
says this is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary PR programs 
for those with moderate to very severe COPD. There must be a referral from the doctor treating the disease. 
The services must be provided in a doctors office or an outpatient hospital setting. The PR program must 
include specific components. Benefits are limited to a maximum of 36 visits, with an additional 36 visits if 
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 pulmonary rehabilitation services. Our 
reviewer says that the requested pulmonary rehabilitation services are not medically necessary. Our physician 
reviewer found the provided records do not support that you have a diagnosis of chronic obstructive pulmonary 
disease (COPD). Therefore, the reviewer found that the requested pulmonary rehabilitation services 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 pulmonary rehabilitation services have not been met. Therefore, we decided that 
the Plan does not have to pre-approve pulmonary rehabilitation services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia (D9243/D9239), a bone replacement graft for 
ridge preservation (D7953), and an extraction (D7210) provided on August 11, 2022. 
 
You asked the Plan to pay for D9243, D9239, D7953, and D7210. You say that this was an emergency. The 
Plan denied your request. The Plan says these services are not covered. 
 
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 anesthesia 
(D9243/D9239), a bone replacement graft for ridge preservation (D7953), and an extraction (D7210) provided 
on August 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-electric hospital bed (E0260). 
 
You asked the Plan to pre-approve a semi-electric hospital bed. You say that the item is medically necessary. 
The Plan denied your request. The Plan says the item is not medically necessary. 
 The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 semi-electric hospital bed. Our 
reviewer says that the item is not medically necessary. Our physician reviewer found you do not require 
frequent change in position or positioning not feasible with a standard bed. 
 
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 semi-electric hospital bed have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a semi-electric hospital bed (E0260).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for pathology services provided to the enrollee on July 8, 2022.

You asked the Plan to pay for these services. The Plan denied your request. The Plan says the required billing
criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and provided
additional information. The Plan provided documentation to show for all claims submitted to this Plan, a
taxonomy claim is required for Medicare claims under Box 24J and Box 33b for physician claims.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. In this case, Medicare claims submitted to this Plan require a physician taxonomy
code and the Plan submitted the documentation given to providers that explain this requirement. Therefore, we
decided that the Plan does not have to pay for pathology services provided to the enrollee on July 8, 2022.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 9 additional PT visits, 2 additional OT visits, and 8 home health aide visits.

You asked the Plan to pre-approve 9 additional PT visits, 2 additional OT visits, and 8 home health aide visits. You say that the enrollee's health is in danger. You say that the enrollee cannot wait this long for services. You also say that you do not feel that the enrollee's care has been adequate. The Plan denied your request. The Plan says the services are not medically necessary. 

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.

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 9 additional PT visits, 2 additional OT visits, and 8 home health aide visits. Our reviewer says that the additional services are not medically reasonable and necessary. Our physician reviewer found the provided records do not document any acute or unstable medical conditions or changes in medication or treatment which would necessitate any further skilled therapy or home health aide visits beyond what have already been approved. No medical notes from the enrollee's treating physician are provided documenting an order or need for additional skilled therapy or home health aide services beyond what have been recently approved. The reviewer found that the records support that the approved services are appropriate for the enrollee's needs. Therefore, the reviewer found that the requested for additional services are 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 9 additional PT visits, 2 additional OT visits, and 8 home health aide visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 9 additional PT visits, 2 additional OT visits, and 8 home health aide visits.
.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power wheelchair repairs. 
 
You asked the Plan to pre-approve the requested repairs. You say that the requested items are not new. The 
Plan denied your request. The Plan says the items do not serve a medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The file shows that accent color kits, leg rest cover, top cover, rear and front covers, fender cover, and a front 
swing arm were requested. The items at issue do not serve a purpose that is primarily medical in nature. 
Therefore, we decided that the Plan does not have to pre-approve power wheelchair repairs.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for scanning computerized ophthalmic diagnostic imaging and 
ophthalmological services provided on July 13, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for scanning computerized ophthalmic diagnostic imaging and ophthalmological 
services. You say that the services should be covered. The Plan denied your request. The Plan says this is 
available in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for scanning computerized ophthalmic diagnostic 
imaging and ophthalmological services provided on July 13, 2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a new patient office visit provided on July 
25, 2023. 
 
You asked the Plan to waive the copayment for a new patient office visit. You say that you never saw a doctor. 
The Plan denied your request. The Plan says this cost sharing was charged 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 $30 
copayment for Medicare-covered urgently needed services. 
 
You have been asked to pay a $30 copayment for a new patient office visit. This item/service falls within the 
Medicare-covered 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 a new patient office visit provided on July 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete mandibular denture (D5120). 
 
You asked the Plan to pre-approve the dental services. You say that you need this. 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 December 20, 2021. 
Therefore, we decided that the Plan does not have to pre-approve a complete mandibular denture (D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete denture - maxillary (D5110). 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. 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 September 26, 2020. 
Therefore, we decided that the Plan does not have to pre-approve complete denture - maxillary (D5110).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 45 additional trips for routine transportation. 
 
You asked the Plan to pre-approve the additional trips. You say that the services are medically necessary for 
you to get to your appointments. The Plan denied your request. The Plan says you have exceeded your benefit 
for the year. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 72 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve 45 additional trips for routine transportation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Intensity Modulated Radiation Therapy (IMRT) 
(77386). 
 
You asked the Plan to pre-approve IMRT. You say that the requested IMRT is medically necessary. The Plan 
denied your request. The Plan says there is no high-quality evidence that this type of radiation therapy is 
needed or is effective for the enrollee's cancer. 
 
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 IMRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee is being offered palliative radiation to two sites in the right pelvis. Prior 
radiotherapy was to a completely different site (left humerus) for which cumulative/composite doses would not 
be relevant. IMRT for bone metastases is uncommonly needed for the palliative treatment. There is no 
dosimetric rationale for IMRT or plausible explanation for why IMRT would be needed over 2D or 3D 
radiation. It is the reviewers opinion that IMRT can be considered medically necessary (even for palliation 
and/or non-standard indications) when justified by quantitative dose measures, when the dose-volume exposure 
of critical structures is unacceptable without IMRT. For this case, the need for IMRT is not justified based 
upon quantifiable dosimetric measures or a plausible rationale. The American Society for Therapeutic 
Radiology and Oncology model policy emphasizes the need to support IMRT with dosimetry; this would be of 
particular importance for clinical scenarios for which IMRT is not considered standard. The decision is 
unfavorable for this case as IMRT would not be furnished in accordance with accepted standards of medical 
practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IMRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Intensity Modulated Radiation Therapy (IMRT) (77386).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral evaluation - problem focused (D0140) provided 
on August 10, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. 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 January 26, 2023. 
Therefore, we decided that the Plan does not have to pay for limited oral evaluation - problem focused (D0140) 
provided on August 10, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Entyvio. 
 
You asked the Plan to pre-approve Entyvio. You say that ongoing denial will put the patient in danger. The 
Plan denied your request. The Plan says that self-administered drugs do not fall under Medicare 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 Entyvio.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crown-porcelain/ceramic substrate (D2740). 
 
You asked the Plan to pre-approve crown-porcelain/ceramic substrate. You say that this should be covered. The 
Plan denied your request. The Plan says this is not a covered service. 
 
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 
crown-porcelain/ceramic substrate (D2740).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Stryker BIO4 allograft (20930). 
 
You asked the Plan to pre-approve a Stryker BIO4 allograft. You say that this is medically necessary. The Plan 
denied your request. The Plan says the clinical value and effectiveness of the Stryker BIO4 Allograft in the 
setting of anterior cervical spine fusion surgery have not been demonstrated in the peer-reviewed literature. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a Stryker BIO4 allograft. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found BIO4 allograft is experimental and not medically needed. 
 
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 Stryker BIO4 allograft have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Stryker BIO4 allograft (20930).