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

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the enrollee has chronic low back 
pain, and nothing has provided sustainable relief. You say that this is a medically necessary procedure, and the 
clinical documentation supports an overturn of the denial. The Plan denied your request. The Plan says this 
service is considered experimental and 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 the Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the cause of pain is not clear and there is no imaging showing only Modic changes 
without facet degenerative joint disease or stenosis.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on July 3, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you were 
having a medical emergency so your wife called 911. You also say that you were advised not to go to the 
hospital but instead to follow up with your physician or go to urgent care. The Plan denied your request. The 
Plan says these services are not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on July 3, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on July 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive periodontal evaluation - new or established 
patient (D0180) provided on September 21, 2023. 
 
You asked the Plan to pay for comprehensive periodontal evaluation. 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 pay for 
comprehensive periodontal evaluation - new or established patient (D0180) provided on September 21, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lightweight 3-wheeled walker (E1399). 
 
You asked the Plan to pre-approve a lightweight 3-wheeled walker. You say that the item should be covered. 
The Plan denied your request. The Plan says you were already approved a standard walker with seat. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a standard walker with seat. a standard walker with seat serves the same purpose 
as a lightweight 3-wheeled walker. Therefore, we decided that the Plan does not have to pre-approve a 
lightweight 3-wheeled walker (E1399).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH care is necessary. The Plan 
denied your request. The Plan says LTACH care is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation provided indicating medical necessity for admission to a 
LTACH. You do not require services at the LTACH that are not available at the acute care hospital where you 
are currently receiving care. There are no services available at the LTACH that you require which are not 
available at the health care setting being offered by the health plan.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided on April 18, 2023. 
 
You asked the Plan to pay for the dental services. You say that the agent never told you about the deadline for 
the reimbursement. The Plan denied your request. The Plan says the claim was received after 120 days from the 
date of service. 
 
Medicare generally does not cover supplemental benefits. However, the Plan offers a dental benefit that 
exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows that a claim for the dental services was not filed until September 21, 2023. This means that 
more than 120 days from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for the dental services. Therefore, we decided that the Plan does not have to pay 
for the dental services provided on April 18, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tetanus vaccination provided on October 31, 2022. 
 
You asked the Plan to pay for the vaccination. You say that the enrollee was unaware that the vaccine was not 
going to be covered. The Plan denied your request. The Plan says there is no indication of risk of acute injury 
justifying coverage under Part B benefits. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccination. The 
Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the vaccination. 
Therefore, we decided that the Plan does not have to pay for the Tetanus vaccination provided on October 31, 
2022.  
 
Benefits for the vaccination 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4342).  
 
You asked the Plan to pre-approve 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 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 11, 2023. 
Therefore, we decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4342).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on July 13, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the home visit. You say that you are appealing the claim payment denial. The 
Plan denied your request. The Plan says the services were provided out-of-network and were not approved in 
advance. 
 
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 the home visit provided on July 13, 2023, by an 
OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the transit equipment and under seat pouch. 
 
You asked the Plan to pre-approve the transit equipment and under seat pouch. You say that the items should 
be covered. The Plan denied your request. The Plan says the transit equipment is used for transportation, not in 
one's home, and the under-seat pouch is a convenience item that does not primarily 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 item must be used primarily in one's home for Medicare to cover it. 
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve the transit equipment and under seat pouch.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-face-to-face non-physician telephone services 
(98968), subsequent hospital inpatient or observation care (99232), and hospital inpatient or observation 
discharge day management (99239) provided on June 9, 2023, to, June 10, 2023.  
You asked the Plan to pay for the non-face-to-face non-physician telephone services (98968), subsequent 
hospital inpatient or observation care (99232), and hospital inpatient or observation discharge day management 
(99239). You say that the enrollee had to visit the emergency room because they had food stuck in their throat. 
The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the non-face-to-face non-physician telephone services 
(98968), subsequent hospital inpatient or observation care (99232), and hospital inpatient or observation 
discharge day management (99239) provided on June 9, 2023, to, June 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral evaluation (D0140) provided on June 23, 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 May 8, 2023, and June 
20, 2023. Therefore, we decided that the Plan does not have to pay for limited oral evaluation (D0140) 
provided on June 23, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pancreatitis panel test. 
 
You asked the Plan to pre-approve the requested testing. You say that the enrollee has had episodes of 
pancreatitis with no clear etiology. The Plan denied your request. The Plan says the test is not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 We looked at the file and Medicare rules. The requested test has not been assessed and shown to meet the 
Medicare reasonable and necessary requirement. Based on this information, we decided that Medicare rules for 
coverage of the requested testing have not been met. Therefore, we decided that the Plan does not have to pre-
approve a pancreatitis panel test.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient diagnostic tests and outpatient 
surgeries provided on June 23, 2023, to July 28, 2023. 
 
You asked the Plan to waive the copayment for an outpatient diagnostic tests and outpatient surgeries. You say 
that you disagree with the copayment. 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 $100 
copayment for outpatient diagnostic tests/Medicare-covered diagnostic radiology services and a $150 
copayment per visit for outpatient surgery/other outpatient procedures.  You have been asked to pay a $100 copayment for an outpatient diagnostic test and a $150 copayment per visit 
for outpatient surgeries. The total amount you are being asked to pay for outpatient surgeries $600 ($150 x 4 
days = $600). The  total amount you are being asked to pay for all services rendered is $700 ($600 + $100 = 
$700).This item/service falls within the outpatient diagnostic tests/Medicare-covered diagnostic radiology 
services and outpatient surgery/other outpatient procedures 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 an outpatient diagnostic tests and outpatient surgeries provided on June 23, 2023, to 
July 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided by a chiropractor on July 10, 2023. 
 
You asked the Plan to pay for the office visit. You say that that you were referred to the chiropractor because 
you tried physical therapy for your severe hip pain, and it did not help. The Plan denied your request. The Plan 
says an office visit is not a covered benefit when billed by a chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit provided by a chiropractor on July 10, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a Dexcom G6 continuous glucose monitor for
the enrollee.

You asked the Plan to provide coverage for a Dexcom G6 continuous glucose monitor. You say that this device
is medically necessary. The Plan denied your request. The Plan says the 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 is correct in this case. The Plan must follow Medicare rules. Medicare rules say that therapeutic
CGMs are considered medically reasonable and necessary when prescribed in accordance with their FDA
indications for enrollees with diabetes who are insulin treated or who have a history of problematic
hypoglycemia and have had an in-person visit with their treating physician to evaluate their diabetes control
and determine whether the criteria for coverage have been met. Based on the medical records provided, all of
the required coverage criteria are not met. Therefore, we decided that the Plan does not have to provide
coverage for a Dexcom G6 continuous glucose monitor for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for an X-Ray examination provided outside of the Plan's service area on 
July 19, 2023. 
 
You asked the Plan to pay for X-Ray. You say that you are appealing with supporting records. The Plan denied 
your request. The Plan says that this provider is out-of-network with the Plan and authorization was not 
obtained. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis, and 
pre-approved care.   
 
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 pay for X-Ray. Our reviewer says that this service 
meets criteria for payment. Our physician reviewer found the enrollee could not have foreseen requiring this 
service prior to leaving the Plan's service area. The records indicate this was medically necessary for testing 
and treatment of an ankle fracture. It would not have been medically reasonable to delay this service until the 
enrollee returned to the Plan's service area. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of X-Ray have been met. Therefore, we decided that the Plan has to pay for an X-
Ray examination provided outside of the Plan's service area on July 19, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH level of care is the only option 
for a safe discharge due to the enrollee's need for frequent nursing care, daily physician management by several 
specialties, telemetry, continuous pulse oximetry, frequent vitals, daily labs, physical, occupational and speech 
therapy. The Plan denied your request. The Plan says an LTACH admission is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the documentation does not support that LTACH services are medically 
appropriate. The enrollee is receiving the appropriate care in the current acute care setting as provided by the 
Health Plan. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service and ground mileage provided on July 3, 
2023. 
 You asked the Plan to pay for the ambulance services. You say that the services were medically necessary and 
therefore payable. The Plan denied your request. The Plan says the enrollee was transported from a non-
covered destination. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when 
they meet certain origin and destination requirements. A doctors office is not a covered destination.  
 
The services you have asked the Plan to pay for are ambulance transport services to a doctors office. 
Therefore, we decided that the Plan does not have to pay for ambulance service and ground mileage provided 
on July 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on August 22, 
2023. 
 
You asked the Plan to pay for the dental service. You say that you went to the dentist to check your teeth that 
they already fixed because you were in pain. 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 the Plan paid for a limited oral evaluation (D0140) on May 23, 2023, and June 5, 2023; therefore, your 
benefit for the requested item or service was exhausted on the date of service of June 5, 2023. Therefore, we 
decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on August 22, 2023.