Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve an MRI of the brain.  
 
You asked the Plan to pre-approve an MRI of the brain. You say that your provider wants to compare your 
previous MRI to a more recent MRI with contrast. The Plan denied your request. The Plan says that the 
requested MRI is not medically necessary.  
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an MRI of the brain. Our physician 
reviewer found that Medicare regulations state that MRI is covered when it is reasonable and necessary. You 
are suspected of having a degree of cognitive impairment/dementia. Performance of an imaging study to rule 
in/out an intracranial process as a cause of symptoms has been requested. This is otherwise a standard of 
care/practice in the evaluation of dementia. In this setting, the requested study would be consistent with 
standards of care and would therefore fall within the scope of being reasonable and 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 an MRI of the brain have been met. Therefore, we decided that the Plan has to 
pre-approve an MRI of the brain.   
 
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for GeneStrat next generation sequencing testing rendered to the enrollee on July 31, 2022.

You asked the Plan to pay for  these services. You say that this claim should be paid.  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. 

Our Medical Director looked at the case file and the reopen request. At issue is coverage for GeneStrat next generation sequencing. 
The medical records show the enrollee was a then 84-year-old man with a diagnosis of non-small cell lung cancer. The Plan is correct in this case. The limited clinical documentation available in the case file does not sufficiently support that the enrollee has recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer, has not been previously tested using the same NGS test for the same primary diagnosis of cancer, and has decided to seek further cancer treatment. 

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  GeneStrat next generation sequencing testing rendered to the enrollee on July 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) for tooth number 18. 
 
You asked the Plan to pre-approve the dental services. You say that your crown has fractured causing your 
gums to swell when food accumulates. 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 21, 2021. 
Therefore, we decided that the Plan does not have to pre-approve a crown (D2740) for tooth number 18.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for  Proton Beam Therapy (PBT) with Image Guided Radiation Therapy (IGRT) for the enrollee. 

You asked the Plan to provide coverage for  Proton Beam Therapy (PBT) with Image Guided Radiation Therapy (IGRT). You say that this treatment is medically necessary.  The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria. 

Our Medical Director looked at the case file and the reopen request. At issue is coverage for Proton Beam Therapy (PBT) with Image Guided Radiation Therapy (IGRT). The medical records show the enrollee has a diagnosis of very high-risk prostate cancer. The enrollee has a history of colon cancer which was surgically removed. The enrollee underwent prostatectomy on November 10, 2022. Pathology showed tumor involving 70% of prostate glands, bilateral seminal vesicle invasion, multifocal extraprostatic invasion, invasion of the bladder neck, angiolymphatic and perineural invasion, and one out of four pelvic lymph nodes involved with extranodal extension. The Plan is correct in this case. There is no applicable CMS guidance for the provider and enrollee's geography.  
The NCCN Panel believes no clear evidence supports a benefit or decrement to proton therapy over IMRT for either treatment efficacy or long-term toxicity. Conventionally fractionated prostate proton therapy can be considered a reasonable alternative to x-ray-based regimens at clinics with appropriate technology, physics, and clinical expertise. In addition, The American Society for Radiation Oncology (ASTRO) evaluated proton therapy and created a model policy to support the society's position on payment coverage for proton beam therapy in 2014.498 This model policy was updated in 2017 and recommends coverage of proton therapy for the treatment of non-metastatic prostate cancer if the patient is enrolled in either an institutional review board (IRB)-approved study or a multi-institutional registry that adheres to Medicare requirements for Coverage with Evidence Development (CED). The case file does not contain documentation of the enrollee being enrolled in such an institutional review board (IRB)-approved study or a multi-institutional registry. The documentation is insufficient to support that PBT with IGRT is medically reasonable and necessary for the enrollee in this case.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of  Proton Beam Therapy (PBT) with Image Guided Radiation Therapy (IGRT) have not been met. Therefore, we decided that the Plan does not have to provide coverage for  Proton Beam Therapy (PBT) with Image Guided Radiation Therapy (IGRT) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of an implant body: endosteal 
implant (D6010), a prefabricated abutmentincludes modification and placement (D6056), and an implant 
supported crown-porcelain fused to high noble alloys (D6066). 
 
You asked the Plan to pre-approve these dental items/services. You say that you are requesting a 
reconsideration of the Plan's denial. The Plan denied your request. The Plan says the requested dental 
items/services are not covered under the supplemental dental policy.  
 
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/services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
surgical placement of an implant body: endosteal implant (D6010), a prefabricated abutmentincludes 
modification and placement (D6056), and an implant supported crown-porcelain fused to high noble alloys 
(D6066).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary complete denture (D5110) and mandibular 
partial denture (D5214). 
 
You asked the Plan to pre-approve the dental services. You say that the dentures you received in 2021 do not fit 
well. 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 July 13, 2021. Therefore, 
we decided that the Plan does not have to pre-approve a maxillary complete denture (D5110) and mandibular 
partial denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an occlusal guard (D9945). 
 
You asked the Plan to pre-approve the dental services. You say that you are in pain from grinding your teeth 
and need the occlusal guard in order to prevent a surgery. The Plan denied your request. The Plan says this 
service is not a covered benefit under your dental 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, 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 an 
occlusal guard (D9945).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement graft for ridge preservation 
(D7953), and a pontic crown (D6245). 
 
You asked the Plan to pre-approve D7953 and D6245. You say that you need these implants because you need 
a bridge. The Plan denied your request. The Plan says the requested services are not covered benefits. 
 
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 a 
bone replacement graft for ridge preservation (D7953), and a pontic crown (D6245).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a private hospital room on September 12, 2021. 
 
You asked the Plan to pay for a private hospital room. You say that this was medically necessary. The Plan 
denied your request. The Plan says this was 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 pay for a private hospital room. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the provided documentation described the enrollee's caregiver requesting a private 
room at the time, but no clinical indication for such was provided. A semi-private room was approved for this 
enrollee. The extra cost of the private room was not justified to be covered by the Plan based on the provided 
documentation.  
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 private hospital room have not been met. Therefore, we decided that the Plan 
does not have to pay for a private hospital room on September 12, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued physical therapy (PT) services. 
 
You asked the Plan to pre-approve the therapy services. You say that the enrollee has cervical and shoulder 
pain with limited range of motion. The Plan denied your request. The Plan says the requested services are not 
medically reasonable and 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 the enrollee has previously been treated with outpatient therapies and 
should be independent with a home exercise program. There is no documentation of a recent injury or decline 
in function. The additional therapy services are not an appropriate duration and frequency for treatment of the 
enrollees medical condition and therefore 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 the therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued physical therapy (PT) services.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the molecular pathology procedure provided on January 28, 
2022. 
 You asked the Plan to pay for the molecular pathology procedure. You say that the services were medically 
necessary. 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 molecular pathology procedure provided on January 28, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator for 3 months (E0466). 
 
You asked the Plan to pre-approve a ventilator for 3 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 3 months. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the provided office notes do not provide any details with regard to the need for a ventilator or failure of a bilevel positive airway pressure 
(BiPAP) device with average volume assured pressure support (AVAPS) and a back-up rate as detailed in the 
letter of necessity. 
 
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 3 months have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a ventilator for 3 months (E0466).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the thoracic 
spine. 
 
You asked the Plan to pre-approve the MRI. You say that the enrollee has a rapidly growing mass on her back 
and requires an MRI to rule out malignancy. The Plan denied your request. The Plan says the criteria for 
coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the MRI. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the enrollee has a dorsal soft tissue mass 
4.7x1.0x5.2 cm which was thought a year ago to be a lipoma. However, the mass has rapidly grown in 
size. MRI of the thoracic spine without contrast, the requested exam, would not be the appropriate imaging 
test. While MRI is definitely indicated due to the increasing size, a more appropriate imaging test would be 
MRI of the chest without and with contrast. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance imaging (MRI) of the thoracic spine.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mandibular partial denture (D5226). 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing 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 December 14, 2020. 
Therefore, we decided that the Plan does not have to pre-approve a mandibular partial denture (D5226).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the thorax. 
 
You asked the Plan to pre-approve the CT scan. You say that your doctor performed x-rays on your neck and 
recommended further imaging via CT scan. The Plan denied your request. The Plan says the criteria for 
coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the CT scan. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found during the encounter of May 9, 2023, there is 
mention of a 5 mm nodule on CT scan of December 2016 and a repeat of December 2017 and then it appears 
another was ordered for 2020. There are no CT reports in the submitted records. Without such reports the 
medical necessity of the requested CT of the chest cannot be established with the submitted records. 
 
 
  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 CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a computed tomography (CT) scan of the thorax.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental services. 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says these services are not covered under the Plan's dental benefits. 
 
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 the 
dental services.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve surgical placement of an implant body: endosteal implants  
(D6010 x 2) and the inhalation of nitrous oxide/analgesia, anxiolysis (D9230). 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says that the requested dental implants are not covered 
under your supplemental dental policy. Additionally, the Plan says that the inhalation of nitrous oxide is not 
medically necessary.   
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has stated that the dental implants requested in this case 
are not covered under the supplemental dental policy and the request for inhalation of nitrous oxide is not 
medically necessary. However, a review of the 2023 Evidence of Coverage contract indicates that the requested 
dental implants are a covered benefit under the dental policy and therefore, the inhalation of nitrous oxide 
would be medically necessary for the procedure. Additionally, dental records were requested in this case; 
however, the Plan has not provided any evidence of their attempts to receive these records. The Plan has not 
substantiated their denial; therefore, we must find in your favor. Therefore, we decided that the Plan has to pre-
approve surgical placement of an implant body: endosteal implants (D6010 x 2) and the inhalation of nitrous 
oxide/analgesia, anxiolysis (D9230).  
 
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.