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

 
We decided that the Plan does not have to pre-approve a kyphoplasty at L1. 
 
You asked the Plan to pre-approve a kyphoplasty at L1. 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 follows Medicare rules. Medicare rules say that kyphoplasty is only covered for certain 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 a kyphoplasty at L1. Our reviewer says 
that the documentation does not support that the requested services are medically reasonable or necessary. Our 
physician reviewer found the enrollee was being treated for closed stable burst fracture of the first lumbar 
vertebra. The enrollee presented with pain that is rated nine to 10 out of 10 in the back with bilateral lower 
extremity weakness. The enrollee notes this pain for six months. The enrollee has had frequent falls. The 
symptoms are progressively worsening. Magnetic resonance imaging (MRI) of the thoracolumbar spine was 
noted to show multilevel spondylosis and degenerative. The exam reveals pain-limited strength throughout. 
The MRI from May 24, 2023, corroborates an acute or subacute L1 burst fracture with approximately 50% 
height loss anteriorly. However, the progress report dated June 20, 2023, states that this pain has been ongoing 
for six months. This would not be considered an acute/subacute problem. Moreover, the MRI corroborates 
additional pathology that plausibly could be causing the noted back pain and symptoms. This is corroborated 
by the subjective complaints of bilateral lower extremity weakness. Also noted on the MRI is fracture 
retropulsion with mild ventral thecal sac indentation, a relative contraindication. Therefore, the enrollee does 
not meet the criteria for the requested services and the requested kyphoplasty at L1 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 a kyphoplasty at L1 have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a kyphoplasty at L1.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.

You asked the Plan to provide coverage for IRF care for the enrollee. The Plan denied your request. The Plan says Medicare coverage criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria. 

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. The medical records show the enrollee had Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an allograft (20930) for spinal surgery. 
 
You asked the Plan to pre-approve an allograft. You say that an allograft is a medical necessity for the enrollee. 
The Plan denied your request. The Plan says an allograft is experimental/investigational. 
 
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 an allograft. Our reviewer says that the 
requested service is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is limited published, large-scale, long-term, peer-reviewed literature that shows this requested 
allograft to be an effective and/or safe treatment for the enrollee's pathology. Further studies are needed to demonstrate this request has beneficial outcomes compared with conventional treatment. There is no 
compelling rationale 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 an allograft have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an allograft (20930) for spinal surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  physical therapy and home nursing care provided in Iran on 
September 7, 2022.  
 
You asked the Plan to pay for  the physical therapy and home nursing care provided in Iran. You say that the 
care in dispute was recommended by your providers. The Plan denied your request. The Plan says the type of 
services in dispute are non-covered when provided outside of the United States.  
 
Medicare says that items and services provided outside of the United States (US) are generally not covered. 
The Plan contract says that it covers worldwide emergency and urgent care services outside of the United 
States under certain circumstances. The Plan contract says that any follow-up care including after-care, 
rehabilitation, physician visits, and skilled nursing facility stays are not considered emergent or urgently 
needed care and are not covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the physical therapy and home nursing care provided in Iran have not been met. Therefore, we 
decided that the Plan does not have to pay for  physical therapy and home nursing care provided in Iran on 
September 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for these services a pontic (D6245) provided on January 4, 2023. 
 
You asked the Plan to pay for these services the dental services. You say that the services should be covered as 
you disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they 
do not fall within 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 Plan's 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 these 
services a pontic (D6245) provided on January 4, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fixed partial denture sectioning (D9120) provided on 
January 19, 2023. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the service provided is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the fixed partial 
denture sectioning (D9120) provided on January 19, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a gingival flap procedure described by code D4241. 
 
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. 
 
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 these services 
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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the approved osseous surgery includes 
the requested gingival flap procedure. The services do not need to be separately approved. 
 
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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a gingival flap procedure described by code D4241.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection device (E2311).  
 
You asked the Plan to pre-approve an electronic connection device. You say that you are requesting 
reconsideration of the denied authorization. The Plan denied your request. The Plan says this item is 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 an electronic connection device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that you have adequate strength to manage the standard power drive 
controls. The requested electronic connection device is not necessary to meet your needs. 
 
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 electronic connection device have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an electronic connection device (E2311).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve six physical therapy visits. 
 
You asked the Plan to pre-approve the therapy services. You say that you need to continue therapy because you 
are worried about mobility and pain. The Plan denied your request. The Plan says the additional physical 
therapy visits are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that you have had extensive prior therapy. You also have had 
instruction in a home exercise program and are independent in this program. The requested additional sessions 
do not require ongoing skilled professional therapy. 
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve six physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator for 6 months (E0466). 
 
You asked the Plan to pre-approve a ventilator for 6 months. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator for 6 months. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found continuation of the home 
ventilator is not medically necessary. The ventilator is being used in the average volume-assured pressure 
support-automated expiratory (AVAPS-AE) mode, which can be provided with bi-level positive airway 
pressure (BiPAP). Medicare does not cover a home ventilator for the treatment of obesity hypoventilation 
syndrome (OHS), or when used at settings that can be provided with BiPAP. The ventilator has been approved 
for 3 months to provide time for transition to BiPAP. 
 
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 ventilator for 6 months have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a ventilator for 6 months (E0466).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) 
provided on October 28, 2022. 
 
You asked the Plan to pay for the dental codes represented by D0220, D0230, D2140, D2954 and D0140. You 
say that this was your first visit to see a dentist and use your dental benefits. You also say that you  have not 
used the benefit since you joined the Plan in 2022. The Plan denied your request. The Plan says your benefit for 
the limited oral evaluation - problem focused 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 Plan's 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 limited oral evaluation - problem focused was exhausted on date of service April 25, 
2022. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation - problem 
focused (D0140) provided on October 28, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an acute inpatient admission. 
 
You asked the Plan to pre-approve an inpatient admission. You say that you are requesting reconsideration of 
the denied authorization. The Plan denied your request. The Plan says the requested inpatient admission is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,  
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an inpatient admission. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that the provided records do not document that the enrollee will require inpatient 
hospital care which will span two midnights for the approved lumbar surgery. 
 
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 inpatient admission have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an acute inpatient admission.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an alignable system described by code L5910. 
 
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 that the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the Medicare rules do not restrict the use of 
L5910 with the approved L5540 prosthesis. It is clinically difficult to imagine building any functional lower 
extremity prosthesis without an alignable system. The alignable system is within the standard of care and is 
reasonable and medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pre-
approve an alignable system described by code L5910.  
 
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 pay for the periodontal maintenance (D4910), and application of 
desensitizing medicament (D9910) provided on January 12, 2023. 
 
You asked the Plan to pay for the dental services represented by codes D0120, D0274, D0330, D1206, D4910 
and D9910. You say that if you had known that the provider was out-of-network you would have not seen the 
provider.  
 
The Plan denied your request. The Plan says codes D4910 and D9910 are not included in your dental benefits. 
In the future, if you wish to continue to see an out of network provider, please obtain pre-approval from the 
plan or your primary care provider. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
periodontal maintenance (D4910), and application of desensitizing medicament (D9910) provided on January 
12, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an expandable controller with harness and electronic connection. 
 
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 that the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the enrollee is non-ambulatory and requires 
a power wheelchair for mobility and performing basic daily activities. He cannot perform pressure relief 
independently due to upper extremity weakness and requires a power wheelchair with power tilt and recline for 
adequate pressure relief and positioning. He requires power elevating leg rests for positioning of his lower 
extremities and lower extremity spasticity. The complexity of his seating and positioning needs necessitates a 
more complex group 3 power wheelchair base. The expandable controller with harness and electronic 
connection are necessary to operate the group 3 power wheelchair base and the three power options via a 
joystick. The services are reasonable and medically necessary for the enrollee 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 these services have been met. Therefore, we decided that the Plan has to pre-
approve an expandable controller with harness and electronic connection.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bioactive 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 requested bioactive allograft is 
considered experimental in nature. The iliac crest autograft is the gold standard. The requested bioactive 
allograft is not reasonable or medically necessary at this time.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a bioactive allograft.