Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the porcelain/ceramic crown (D2740) and post and core in
addition to a crown (D2952) rendered on October 17, 2022.

You asked the Plan to pay for the dental services. You say that 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 Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record
shows your benefit for the requested item or service was exhausted. The file
shows that a transaction  was paid for services rendered on January 26, 2022; for services rendered
on July 6, 2022;  for services rendered on August 23, 2022; and for services rendered on October 4,
2022. This equals a total of $1,250 for supplemental dental benefits. Further coverage is not allowed by your
supplemental benefit or Medicare.

Therefore, we decided that the Plan does not have to pay for the porcelain/ceramic crown (D2740) and post and
core in addition to a crown (D2952) rendered.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the flow cytometry provided on January 4, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that flow cytometry is covered for the indications 
established in the applicable LCD. 
 
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 services. Our reviewer says that the 
requested flow cytometry is not medically reasonable and necessary. Our physician reviewer found that the 
documentation states the enrollee had flow cytometry testing for heart failure/respiratory insufficiency, which 
is not the standard of care, and not indicated criteria for coverage in the LCD. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for the flow cytometry provided on January 4, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve prosthetic parts (L5781, L5973).  
You asked the Plan to pre-approve the items. You say that this is medically necessary. The Plan denied your 
request. The Plan says that experimental and investigational items are not covered. 
 
The Plan must follow Medicare rules. The rules say that coverage is extended only if there is sufficient clinical 
documentation of functional need for the technologic or design feature of a given type of foot. 
 
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 items. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that the medical record provided - i.e., the certified prosthetist/orthotist (CPO) note from August and the 
appeal letter, corroborated by the primary care physician (PCP) clinic note from July - more than satisfies the 
documentation requirements for the components in question. 
 
Dealing first with the question of L5973, this hinges on whether or not the enrollee qualifies for a replacement 
of the existing K3 foot at this time. One of the criteria that is sufficient for replacement of a 
prosthesis/component per Policy Article A52496 is change in the physiological condition of the 
beneficiary.  The Plan seems to have accepted that such a change (significant weight gain) has occurred by 
virtue of approving the replacement socket. This same physiological change requires that he have a new foot, 
because the warranty on his existing foot will not furnish an entirely new one with higher weight rating based 
on his weight change. Beyond that, there appears to be no controversy that he is a K3 ambulator, and the LCD 
explicitly covers L5973 as one of the classes of feet available to any K3 ambulator as a part of the standard of 
care. 
 
Regarding L5781, the plan's main arguments centers on its Omnibus Codes policy, which declares this 
technology to be experimental and generally non-covered. However, L5871 is very much in the mainstream of 
standards of care for prosthetics.  
 
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 items have been met. Therefore, we decided that the Plan has to pre-approve 
prosthetic parts (L5781, L5973).  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the FreeStyle Libre. You say that you are a diabetic and have been taking 
Metformin, Farxiga and using the FreeStyle for the past 15 years. You also say that when you poke your 
fingers no blood comes out and you have pain in your fingers all day.  The Plan denied your request. The Plan 
says the requested CGM does not meet the medical necessity criteria. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the FreeStyle Libre. Our reviewer says 
that this item is not medically necessary. Our physician reviewer found the record indicates that you have 
diabetes. The record does not indicate that you are being treated with insulin or have problematic hypoglycemia 
as defined by Medicare rules. The elements of the coverage criteria are not satisfied. 
 
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 FreeStyle Libre have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a FreeStyle Libre continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for Transcutaneous Electrical Nerve Stimulators (TENS) unit
supplies billed to the enrollee.

You asked the Plan to pay for this claim. You say that the Plan denied your request. The Plan says the
Medicare billing criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and
noted that the provider has been submitting claims for A4595 Electrical stimulator supplies, 2 lead, per month
since June 3, 2022. Based on the Medicare guidelines, for supplies that are provided on a recurring basis,
suppliers are required to have contact with the beneficiary or caregiver/designee prior to dispensing a new
supply of items. Suppliers must not deliver refills without a refill request from a beneficiary. Items delivered
without a valid, documented refill request will be denied as not reasonable and necessary. Suppliers must not
dispense a quantity of supplies exceeding a beneficiary's expected utilization. Suppliers must stay attuned to
changed or atypical utilization patterns on the part of their clients. Suppliers must verify with the treating
practitioners that any changed or atypical utilization is warranted. Regardless of utilization, a supplier must not
dispense more than a three (3) - month quantity at a time. The provider did not submit any evidence that they
have been contacting the member before shipping additional supplies. A 4-lead TENS unit may be used with
either 2 leads or 4 leads, depending on the characteristics of the beneficiary's pain. If it is ordered for use with 4
leads, the medical record must document why 2 leads are insufficient to meet the beneficiary's needs.
Separate allowance will be made for replacement supplies when they are reasonable and necessary and
are used with a covered TENS. Usual maximum utilization is: 2 TENS leads - a maximum of one unit of
A4595 per month and 4 TENS leads with a maximum of two units of A4595 per month.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. In this case, this claim could not be paid as the required criteria for ordering and
billing for these types of supplies are not met. Therefore, we decided that the Plan does not have to pay for
Transcutaneous Electrical Nerve Stimulators (TENS) unit supplies billed to the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skin substitute grafts. 
 
You asked the Plan to pre-approve skin substitute grafts. You say that you are requesting reconsideration for 
the denied claim. The Plan denied your request. The Plan says the enrollee does not meet the requirements for 
approval.  
 
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 skin substitute grafts. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that in late July, it measured 1.5 x 2 x 2 cm and approximately 1 month later, it was 
0.2 x 0.6 x 0.5 cm. More conservative therapy has not failed and in fact appears to be helping improve the 
wound. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of skin substitute grafts have not been met. Therefore, we decided that the Plan 
does not have to pre-approve skin substitute grafts.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cervical traction device (E0849) provided on March 15, 
2023. 
 
You asked the Plan to pay for the device. The Plan denied your request. The Plan says this is not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that cervical traction devices are covered for the 
indications established in the applicable LCD. 
 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 device. Our reviewer says that the 
requested cervical traction device is not medically reasonable and necessary in this case. Our physician 
reviewer found that the provided records in this case do not document any order for, or necessity of a cervical 
traction device which meet the coverage criteria in the LCD (L33823).  
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pay for the cervical traction device (E0849) provided on March 15, 2023.
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 based on the documentation provided, coverage 
criteria has not been met. The Plan denied your request. The Plan says the services are necessary.  
 
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 enrollee's nursing, medical and rehabilitation can be provided 
in a lower level of care and does not require an acute hospital inpatient stay with an interdisciplinary approach 
to rehabilitation care. The enrollee requires treatment by multiple therapies, including physical therapy and 
occupational therapy, but this can be provided in a lower level of care. There is documentation that there is a 
reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF, but the services required can be provided at a lower 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Dexcom G7 Receiver.

You asked the Plan to pre-approve a Dexcom G7 Receiver. You say that you do not agree with the denial. The
Plan denied your request. The Plan says that you have already been provided a Dexcom G7 Receiver and do
not qualify for a second one. Maximus overturned the Plan's denial based on medical necessity. The Plan
requested a reopening and stated that Maximus did not apply the correct criteria. The Plan is correct in this
case. 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 Dexcom G7 Receiver. A Dexcom G7 Receiver serves the same purpose as the first
Dexcom G7 Receiver you received. Therefore, we decided that the Plan does not have to pre-approve a
Dexcom G7 Receiver.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve F2 (81240) and F5 (81241) gene analyses.  
 
You asked the Plan to pre-approve F2 and F5 gene analyses. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested services are not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that the F2 and F5 genetic tests are not considered to 
be clinically efficacious. Based on this information, we decided that Medicare rules for coverage of F2 and F5 
gene analyses have not been met. Therefore, we decided that the Plan does not have to pre-approve F2 (81240) 
and F5 (81241) gene analyses.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive or reduce the cost share charged for a diagnostic colonoscopy
($325) and computed tomography (CT) scan ($270) provided.

You asked the Plan to waive or reduce this cost share. You say that you do not believe the cost share charged is
correct. The Plan denied your request. The Plan says this cost sharing was charged correctly. Maximus partially
overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct
contract criteria.

The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all
cost sharing information. The enrollee's contract with the Plan clearly says that enrollees must pay $325
copayment for outpatient surgery, which would include colonoscopy services resulting in biopsy or surgical
removal of tissue. The Plan contract also states outpatient imaging services have a copayment of $270.
Based on the records provided, the enrollee was charged the correct cost share based on the services provided,
the claim submitted by the providers and the Plan contract agreement. Therefore, we decided that the Plan does
not have to waive or reduce the cost share charged for a diagnostic colonoscopy ($325) and computed
tomography (CT) scan ($270) provided.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that admission to the IRF is required as the enrollee 
meets the full criteria for an inpatient rehabilitation stay. The Plan denied your request. The Plan says based on 
Medicare guidelines, the IRF services requested do not meet the requirements for approval. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the enrollee's condition is in fact complex and fragile, and there is every reason to expect that they will 
participate in and benefit from IRF-level services to include at minimum physical therapy, occupational 
therapy, respiratory therapy, physician oversight of polypharmacy, and case manager coordination of any 
additional services that might be needed to make a sustainable return home, as well as avoid preventable re-
admissions to the acute hospital. Therefore, the requested inpatient rehabilitation facility admission is 
approved. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing provided on March 3, 2023, billed with codes 
95937, 95938, 95939, 95955, 95860, G0453. 
 
You asked the Plan to pay for the testing. You say that medical records submitted support codes 95937, 95938, 
95939, 95955, 95860, G0453 and should be paid. The Plan denied your request. The Plan says Current 
Procedural Terminology codes 95937, 95938, 95939, 95955, 95860, G0453 are not supported. The CPT codes 
were billed with POS 21 (inpatient hospital); however, the documentation submitted support that the services 
provided were in an outpatient hospital setting (POS 22).  
 
Medicare rules say that the POS code reflects the actual place where the beneficiary receives the face-to-face 
service and determines whether the facility or nonfacility payment rate is paid.  
We looked at the file and Medicare rules. The medical report submitted by the provider documents that the 
services provided were in an outpatient setting (POS 22), which does not support the billed inpatient POS. 
Based on this information, we decided that Medicare rules for coverage of the testing have not been met. 
Therefore, we decided that the Plan does not have to pay for the muscle test, neuromuscular junction test, 
somatosensory test, central motor study of upper and lower limbs, electroencephalogram (EEG), and 
continuous intraoperative neurophysiology monitoring provided on March 3, 2023, billed with codes 95937, 
95938, 95939, 95955, 95860, G0453.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires an LTACH level of 
care and is stable for discharge. The Plan denied your request. The Plan says the enrollee's medical needs are 
being met at the current acute care hospital. 
 
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 the enrollee is receiving an appropriate level of care in the present setting. The 
acute hospital can provide for all the enrollee's present inpatient care needs, and the Plan has stated that 
continued care in the short-term acute hospital will be covered. Continued care in the short-term acute hospital 
is appropriate until the enrollee is stable to transfer to a lower level of care such as an inpatient rehabilitation 
facility, a sub-acute rehabilitation facility or a skilled nursing facility. 
 
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 long term acute care hospital (LTACH) services.