Persius/hicric huggingface dataset:
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. 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 enrollee appears to be getting sicker and is not appropriate for transfer. 
 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve onabotulinumtoxina. 
 
You asked the Plan to pre-approve the medication. You say that the enrollee does not have pharmacy benefits 
and needs this treatment. The Plan denied your request. The Plan says the records show the medication is 
dispensed by the pharmacy and not by a physician. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve onabotulinumtoxina.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs IRF care to optimize her level of 
function prior to returning home. The Plan denied your request. The Plan says the enrollee does not meet the 
requirements for an IRF admission.  
 
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. 
 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollees nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay, with an interdisciplinary approach to rehabilitation care. The enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. There is not a 
reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation program provided in an IRF. Medically necessary care can be provided in a different level of 
care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer. 
 You asked the Plan to pre-approve Injectafer. 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. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Injectafer. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the enrollee has not tried and failed the 
required drugs. There is no documentation provided indicating that the plan's required drugs would likely be 
less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on April 20, 2023. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for the lab services provided on April 20, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Epifix (Q4186) and Epicord (Q4187). 
   
You asked the Plan to pre-approve Epifix and Epicord. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is not medically necessary because the records show the enrollee does 
not have documentation of adequate circulation/oxygenation to support tissue growth/wound healing as 
evidenced by ankle-brachial index readings. Additionally, the simultaneous use of more than one skin 
substitute is not covered. 
 
The Plan follows Medicare rules. Medicare rules say that skin substitutes can be covered when specific criteria 
are met. 
 
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 Epifix and Epicord. Our reviewer says 
that the enrollee does not meet criteria for coverage. Our physician reviewer found the records show that the 
enrollee does not have documentation of adequate circulation/ oxygenation to support tissue growth/wound 
healing as evidenced by ankle-brachial index readings. Additionally, the simultaneous use of more than one 
skin substitute is not covered. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Epifix and Epicord have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Epifix (Q4186) and Epicord (Q4187).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fungal infection polymerase chain reaction (PCR) panel 
testing provided on June 22, 2023, and billed with codes 87801, 87798, and 87481. 
 
You asked the Plan to pay for the fungal infection PCR panel testing. You say that this testing was medically 
necessary. The Plan denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.   
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the fungal infection polymerase chain reaction (PCR) panel testing provided on 
June 22, 2023, and billed with codes 87801, 87798, and 87481.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a fixed prosthodontic (bridge) between teeth #3 and #6
(D6242 and D6740) for the enrollee.

You asked the Plan to pre-approve a fixed prosthodontic. You say that this is medically necessary for the
enrollee. The Plan denied your request. The Plan says that information did not include a physical or
neurological disorder that precludes the use of a removable prosthesis.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for a fixed
prosthodontic. Our Medical Director states that the documentation does not support that the coverage criteria
for a fixed bridge were met in this case. Our Medical Director found that the enrollee's condition does not meet
criteria for coverage of a fixed prosthodontic.

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 a fixed prosthodontic have not been met. Therefore, we decided that the Plan
does not have to pre-approve a fixed prosthodontic (bridge) between teeth #3 and #6 (D6242 and D6740) for
the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral appliance rendered on February 22, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that an oral appliance is covered when specific 
criteria are met. 
 
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 these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the enrollee was evaluated by a 
pulmonologist prior to undergoing a home sleep study. The study showed an apnea-hypopnea index (AHI) of 
10.2. While the enrollee reported not feeling refreshed in the morning, there is no documentation of excessive 
daytime sleepiness, impaired cognition, mood disorder or insomnia.  Additionally, there is no evidence of 
hypertension, ischemic heart disease or stroke.  While the enrollee reported being previously intolerant of a 
CPAP device, there is no evidence of intolerance. The criteria for coverage are not met and the services were 
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 these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the oral appliance rendered on February 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional chiropractic services.

You asked the Plan to provide coverage for these services. You say that the Plan denied your request. The Plan
says the required coverage criteria were not met. Maximus overturned the Plans denial for insufficient records
in the file. The Plan requested a reopen and noted that several attempts were made to get records from your
provider with no response. Your physician must submit clinical documentation showing a treatment plan that
includes recent history and physical, along with goals and duration of treatment. The limited records sent to the
Plan do not show this. The Plan made multiple attempts to obtain the records from your provider, however a
response was not received. Therefore, these services could not be approved by the Plan.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that for Medicare to
consider coverage and payment for any item or service, the information submitted by the supplier or provider
must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare
coverage criteria have been met. Both the Plan and Medicare have specific coverage criteria for this type of
care. We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient
information in the record to determine if Medicare rules for coverage of these services have been met.
Therefore, we decided that the Plan does not have to provide coverage for additional chiropractic services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ketamine injections (J3590). 
 
You asked the Plan to pay for ketamine injections. You say that monthly ketamine infusions are the only thing 
that keeps your back pain under control. The Plan denied your request. The Plan says this drug is not medically 
necessary as it is only covered when provided in conjunction with an anesthesia service for a covered 
procedure. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 ketamine injections. Our reviewer says that 
the requested drug is not medically necessary. Our physician reviewer found Ketamine is considered experimental or investigational when it is being used outside of an anesthesia service for a covered medical 
procedure. Studies have concluded that until definite proof is obtained that the benefits of ketamine are greater 
than its risks, ketamine administration should be restricted to patients with severe and therapy-resistant 
neuropathic pain, such as in the case of chronic, complex refractory regional pain syndrome (CRPS) pain. The 
review has determined that the requested use of ketamine is not FDA-approved for the enrollees diagnosis. Its 
use is not supported by one of the major drug compendia or by clinical research that appears in a Centers for 
Medicare and Medicaid-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ketamine injections have not been met. Therefore, we decided that the Plan does 
not have to pay for ketamine injections (J3590).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gastric peroral endoscopic myotomy (G-POEM) to be 
provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve G-POEM. You say that you need this procedure. The Plan denied your 
request. The Plan says that their original decision to deny coverage was correct, and that there is a network 
provider who can provide this service. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out-of-area urgent care, and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
gastric peroral endoscopic myotomy (G-POEM) to be provided by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311), an expandable 
controller harness (E2313), and an expandable controller (E2377). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that the enrollee has a medical need for 
these items on their power wheelchair. The Plan denied your request. The Plan says the electronic connection, 
expandable controller harness, and expandable controller cannot be covered as it is not medically necessary to 
control the three approved power options through the joystick (drive interface). 
 
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 wheelchair accessories. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has myopathy and polyneuropathy. He has 4/5 strength in upper 
extremities bilaterally. Per Social Security Administration (SSA) 1862 (a)1(A), the enrollee has adequate 
strength to manage standard power drives and does not meet criteria for approval of the requested accessories. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of wheelchair accessories have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an electronic connection (E2311), an expandable controller harness (E2313), and 
an expandable controller (E2377).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the re-evaluation (D0171), the adjunctive pre-diagnostic test 
(D0431), the intraoral complete series of radiographic images (D0210), the surgical stent (D5982), the 
extractions (D7140) for tooth #26 and #31, the placement of intra-socket dressing (D7922) for tooth #31, the 
medicaments (D9630), and the unspecified adjunctive procedure (D9999) provided on December 10, 2021, 
December 14, 2021, January 19, 2022, April 11, 2022. 
 
You asked the Plan to pay for the dental services. You say that the provider verified your coverage for only 
basic services, so you did not file the claim on time. The Plan denied your request. The Plan says your benefit 
for the intraoral complete series of radiographic images and extractions has already been exhausted. Also, the 
re-evaluation, the adjunctive pre-diagnostic test, the surgical stent, the extractions, the placement of intra-
socket dressing, the medicaments, and the unspecified adjunctive procedure are not covered by the Plan. 
 
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 panoramic radiographic image (D0330) on December 19, 2019; therefore, your 
benefit for the intraoral complete series of radiographic images (D0210) was exhausted on the date of service 
of December 19, 2019. The record also shows the Plan paid for the extractions (D7140) for tooth #23 and #24 
on December 10, 2021; therefore, your benefit for the extractions (D7140) for tooth #26 and #31 was exhausted 
on the date of service of December 10, 2021. The re-evaluation, the adjunctive pre-diagnostic test, the surgical 
stent, the extractions, the placement of intra-socket dressing, the medicaments, and the unspecified adjunctive 
procedure are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pay for the re-evaluation (D0171), the adjunctive pre-diagnostic test (D0431), the intraoral complete series of 
radiographic images (D0210), the surgical stent (D5982), the extractions (D7140) for tooth #26 and #31, the 
placement of intra-socket dressing (D7922) for tooth #31, the medicaments (D9630), and the unspecified 
adjunctive procedure (D9999) provided on December 10, 2021, December 14, 2021, January 19, 2022, April 
11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to adjust the cost share outpatient services you received on August 11, 
2023. 
 
You asked the Plan to adjust the copayment. You say that you should only owe a $36 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 $375 
copayment for outpatient surgery.  
 
Review of the file shows that you were provided phlebotomy services on August 11, 2023. The allowed 
amount for this procedure was $80.40. As the allowed amount is less than the $375 copayment required by the 
Plan contract, you have been asked to pay $80.40 for these services. This service falls within the outpatient surgery 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 adjust the cost share outpatient services you received 
on August 11, 2023.