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

 
We decided that the Plan does not have to pre-approve breast reduction (19318). 
 
You asked the Plan to pre-approve the surgical service. You say that the enrollee has had neck, shoulder and 
back pain for at least three years. You say that the enrollee experiences tingling and numbness in hands and 
fingers. You also say that this affects the enrollee's ability to perform activities of daily living, including 
walking, standing, and sleeping. The Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that reduction mammaplasty will be considered medically 
reasonable and necessary when performed to reduce the size of the breasts and help ameliorate symptoms 
caused by hypertrophy when the surgeon's estimate of breast size/weight/volume to be removed is proportional 
to the body surface area (BSA) per the Schnur scale per breast to relieve symptoms. 
 
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 surgical service. Our reviewer says 
that the requested breast reduction is not medically necessary. Our physician reviewer found the provided 
documentation indicates the enrollee has recurrent macromastia. The provided documentation is insufficient to 
demonstrate that the requirements of the coverage rule are satisfied. The reviewer also found that there is no 
documentation indicating that the recommended amount tissue will be removed. Therefore, the reviewer found 
that the requested breast reduction is not medically reasonable or 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 the surgical service have not been met. Therefore, we decided that the Plan does 
not have to pre-approve breast reduction (19318).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block (64624). 
 
You asked the Plan to pre-approve a genicular nerve block. You say that this is medically necessary. The Plan 
denied your request. The Plan says this 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 a genicular nerve block. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this is considered experimental investigational at this time. There is an ongoing 
clinical trial for patients with knee pain post total knee replacement. 
 
   
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 genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a genicular nerve block (64624).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete denture - maxillary (D5110), complete 
denture - mandibular (D5120), and surgical placement of implant body: endosteal implant (D6010). 
 
You asked the Plan to pre-approve the complete maxillary, mandibular dentures, and the surgical placement of 
implant body. The Plan denied your request. The Plan says your benefit for the maxillary and mandibular 
complete dentures has already been exhausted. The Plan also says that the surgical placement of implant body 
is not covered under the benefit package. 
 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 surgical placement of implant body 
is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-
approve a surgical placement of implant body: endosteal implant (D6010). 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the maxillary and mandibular complete dentures was exhausted on date of service 
February 1, 2022. Therefore, we decided that the Plan does not have to pre-approve a complete denture - 
maxillary (D5110), complete denture - mandibular (D5120).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an extra heavy-duty manual wheelchair (K0007).
You asked the Plan to pre-approve an extra heavy-duty manual wheelchair. You say that you have had an
amputation. You say that your foot has been operated on three times. You say that you have staph infections
that have not cleared up. You also say that you need this wheelchair to get to and from the bathroom. The Plan
denied your request. The Plan says that the evidence of mobility limitation that significantly impairs MRADLS
is not clear.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for an extra heavyduty
manual wheelchair. Our Medical Director states that based on the medical records provided there is
inconsistent documentation that you have a personal mobility deficit that impairs participation in mobility
related activities of daily living (ADL's) such as toileting, feeding, grooming and bathing in customary
locations within the home. An occupational therapy note from April 10, 2023 reported you were performing
ADL's independently in your bathroom with no assistive device. There is no documentation that your mobility
deficit cannot be helped using a walker. Physical therapy and occupational therapy notes immediately around
the time of the wheelchair request document you were ambulating with a CAM walking boot on the right lower
extremity with a front-wheeled walker 200 feet with stand-by assistance and were independent with transfers.
Our Medical Director found that your condition does not meet criteria for coverage of an extra heavy-duty
manual wheelchair.
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 extra heavy-duty manual wheelchair have not been met. Therefore, we
decided that the Plan does not have to pre-approve an extra heavy-duty manual wheelchair (K0007).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sleep study (95810). 
 
You asked the Plan to pre-approve a sleep study. You say that this is medically necessary. The Plan denied 
your request. The Plan says the enrollee does not have any qualifying comorbid medical conditions, secondary 
concomitant, chronic opioid use or associated sleep disorder other than suspected OSA which would degrade a 
home sleep test. 
 
The Plan follows Medicare rules. Medicare rules say that a sleep study 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 a sleep study. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found this enrollee has symptoms suggestive of 
obstructive sleep apnea. There is no contraindication to a home sleep study. The enrollee does not have severe 
heart or lung disease, symptoms suggestive of parasomnias or narcolepsy, a seizure disorder, or a BMI greater 
than 45. A home sleep study would be a reasonable initial approach. 
 
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 sleep study have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a sleep study (95810).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the facet joint injection provided on November 17, 2022. 
 You asked the Plan to pay for the injection. You say that you have had this procedure done previously and it 
was covered. The Plan denied your request. The Plan says that the facet joint injection 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 pay for the injection. Our reviewer says that the 
facet joint injection is not medically necessary. Our physician reviewer found that the medical records do not 
detail physical therapy, chiropractic therapy or other conservative therapies. Also, there is no detail regarding 
medication trials or advanced imaging. Therefore, the request is not medically 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 the injection have not been met. Therefore, we decided that the Plan does not 
have to pay for the facet joint injection provided on November 17, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sinus ablation (30117) and repair of nasal valve collapse 
(30469). 
 
You asked the Plan to pre-approve the VivAer procedure. You say that Original Medicare covers nasal airway 
remodeling using the requested procedure codes. The Plan denied your request. The Plan says the clinical value 
and effectiveness of the VivAer procedure in the setting of nasal valve collapse have not been demonstrated in 
the peer-reviewed literature 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the VivAer procedure. Our reviewer 
says that the requested VivAer procedure is not considered medically reasonable and necessary in this case. 
Our physician reviewer found the record indicates that the enrollee has nasal valvular collapse.  There is insufficient literature to support the safety and efficacy of the requested service for the enrollee's specific 
conditions. The record provided does not establish the medical necessity and reasonableness, as defined by 
Medicare rules, of the requested service. Therefore, the reviewer found that the requested VivAer procedure 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 the VivAer procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve sinus ablation (30117) and repair of nasal valve collapse (30469).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral evaluation-problem focused (D0140), intraoral - 
periapical first radiographic image (D0220) and pulp cap (D3120) provided on March 30, 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 limited oral evaluation-problem focused and intraoral - periapical 
first radiographic image 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 limited oral evaluation-problem focused and intraoral - periapical first radiographic image was exhausted on date of service April 24, 2023. Therefore, we decided that the Plan does not have to 
pay for limited oral evaluation-problem focused (D0140), intraoral - periapical first radiographic image 
(D0220) and pulp cap (D3120) provided on March 30, 2023.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve a percutaneous image-guided lumbar decompression (PILD) procedure for the enrollee.
You asked the Plan to pre-approve the PILD procedure. You say that this is a medically necessary procedure. The Plan denied your request. The Plan says that that this cannot be covered as the enrollee is not going to participate in a clinical study. Maximus overturned the Plan's denial. Maximus reopened the appeal because additional information provided was not reviewed prior to the decision.
The Plan must follow Medicare rules. Medicare rules say that that PILD will be covered by Medicare when provided in a clinical study under section 1862(a)(1)(E) of the Social Security Act through Coverage with Evidence Development (CED) for beneficiaries with LSS who are enrolled in an approved clinical study. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the PILD procedure have been met. Specifically, documentation has been provided to indicate the enrollee is enrolled in an approved clinical study. Therefore, we decided that the Plan has to pre-approve a percutaneous image-guided lumbar decompression (PILD) procedure for the enrollee.
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit and scanning computerized ophthalmic diagnostic 
imaging provided on May 10, 2023. 
 
You asked the Plan to pay for office visit and scanning computerized ophthalmic diagnostic imaging. You say 
that the services were medically necessary The Plan denied your request. The Plan says that unauthorized, out-
of-network care is not covered. 
 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for office visit and scanning 
computerized ophthalmic diagnostic imaging provided on May 10, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pr-approve the skilled nursing services. 
 
You asked the Plan to pr-approve the skilled nursing services. You say that the enrollee needs physical therapy 
and occupational therapy and will benefit and improve joint integrity and strength and mobility.  The Plan 
denied your request. The Plan says the enrollees 100-day Medicare inpatient SNF benefit was exhausted as of 
08/13/2023. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that the enrollee received 100 days of SNF care during the benefit period from May 5, 2023, 
through August 14, 2023. The Plan has covered 100 days of SNF care.  
 
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided 
that the Plan does not have to pr-approve the skilled nursing services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill (SSBCI).
You asked the Plan to pre-approve SSBCI benefits. You say that you believe you are eligible for the SSBCI benefits. The Plan denied your request. The Plan says that you do not meet the criteria to be eligible for SSBCI benefits. Maximus overturned the Plan's denial because medical records were not included. The Plan has requested a reopening and provided the Attestation for Special Supplemental Benefits for the Chronically Ill. The Plan has also shown proof that they requested medical records multiple times from your treating physician.
The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a documented chronic condition that is life threatening or significantly limits the health or function of the enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an eligible condition that meets all the required criteria. Your physician confirmed that you do not need intensive care management. Therefore, we decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the periodontal scaling and root planing (D4341) on all 
4 quadrants. 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denied dental 
services because they are necessary. The Plan denied your request. The Plan says the denial of authorization for 
these services is correct, because the periodontal scaling and root planing is 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, 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 
periodontal scaling and root planing (D4341) on all 4 quadrants.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 48 additional routine transportation trips (A0120). 
 
You asked the Plan to pre-approve the additional trips. You say that you say that you need the additional trips 
for your dialysis appointments. The Plan denied your request. The Plan says you currently have 0 trips 
remaining and the 48 additional trips will have exceeded your benefit limit.  
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 48 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to pre-approve the 
additional 48 trips for your dialysis appointments. Based on this information, we decided that you have 
exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the 
Plan does not have to pre-approve 48 additional routine transportation trips (A0120).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sleep study (95810). 
 
You asked the Plan to pre-approve a sleep study. You say that this is medically necessary. The Plan denied 
your request. The Plan says the enrollee does not have any qualifying comorbid medical conditions, secondary 
concomitant, chronic opioid use or associated sleep disorder other than suspected OSA which would degrade a 
home sleep test. 
 
The Plan follows Medicare rules. Medicare rules say that a sleep study 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 a sleep study. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the enrollee had a prior sleep study, not 
provided, that showed OSA. There were no interventions recommended or provided. There is no data to 
suggest repeat testing is indicated. 
 
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 sleep study have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a sleep study (95810).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device. 
 
You asked the Plan to pre-approve the Vertiflex device. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says this is considered experimental and therefore is not 
covered. 
 
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 Vertiflex device. Our reviewer says 
that the requested Vertiflex device is not considered medically reasonable and necessary in this case. Our 
physician reviewer found this device is considered experimental as additional research is needed. Therefore, 
the reviewer found that the requested Vertiflex device 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 the Vertiflex device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sectioning of a fixed partial denture (D9120). 
 
You asked the Plan to pre-approve the dental service. You say that you need the dental service, and you would 
like the Plan to approve it. The Plan denied your request. The Plan says the denial of authorization for this 
service is correct, because the bone replacement graft and guided tissue regeneration 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, the sectioning of a fixed partial denture 
is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-
approve a sectioning of a fixed partial denture (D9120).