Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care related to a total shoulder 
arthroplasty procedure. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the requested inpatient care is a 
medical necessity for the enrollee. The Plan denied your request. The Plan says the request is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. 
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found that detailed documentation is not evident in the case record regarding a 
significant past and/or current medical history that would place the enrollee at increased risk for peri-surgical 
complications requiring an inpatient stay. There is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care related to a total shoulder arthroplasty 
procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a below knee acrylic socket, a flexible inner socket, and 
a suction socket (L5629, L5647, L5645). 
 
You asked the Plan to pre-approve the below knee acrylic socket, a flexible inner socket, and a suction socket. 
You say that this item is medically necessary. The Plan denied your request. The Plan says coverage criteria 
has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that when an initial below knee prosthesis (L5500) or 
a preparatory below knee prosthesis (L5510, L5520,L5530, L5540) is provided, prosthetic substitutions and/or 
additions of procedures and components are covered in accordance with the functional level assessment except for codes L5629, L5638, L5639, L5646, L5647, L5704, L5785, L5962, and L5980 which will be denied as not 
reasonable and necessary.  
 
When a below knee preparatory prefabricated prosthesis (L5535) is provided, prosthetic substitutions and/or 
additions of procedures are covered in accordance with the functional level assessment except for codes L5620, 
L5629, L5645, L5646, L5670, L5676, L5704, and L5962 which will be denied as not reasonable and necessary 
 
We looked at the file and Medicare rules. The requested features are not covered under Medicare rules. Based 
on this information, we decided that Medicare rules for coverage of the below knee acrylic socket, a flexible 
inner socket, and a suction socket have not been met. Therefore, we decided that the Plan does not have to pre-
approve a below knee acrylic socket, a flexible inner socket, and a suction socket (L5629, L5647, L5645).
Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pay for the oxygen concentrator provided August 13, 2022. We decided that 
the Plan does not have to pay for oxygen concentrator provided July 13, 2021, to October 13, 2021.  
 
You asked the Plan to pay for the oxygen concentrator (E1390) provided July 13, 2021, to August 13, 2022. 
You say that it was not until late June when you found out you was being charged the full amount and not just 
the deductible. The supplier is wanting $900 more from you as you cancelled the auto payments. You still have 
the equipment and cannot go without the portable machine. The Plan says that the claims for dates of service 
July 13, 2021, to October 13, 2021, were submitted past the timely filing limitation. The correct cost share has 
been applied for date of service August 13, 2022. 
 
We decided that the Plan has to pay for the oxygen concentrator provided August 13, 2022.  
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information.  
 
The Plan says you must pay $147.51 for the oxygen supplies provided August 13, 2022. Based on the Plan 
contract, however, you cannot be asked to pay more than $29.50 (147.51 x 20%) coinsurance for Medicare 
covered items for the oxygen supplies. Therefore, we decided that the Plan has to pay for the oxygen 
concentrator provided August 13, 2022.  
 
We also decided that the Plan does not have to pay for oxygen concentrator provided July 13, 2021, to 
October 13, 2021. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the oxygen supplies was not filed until October 24, 2022. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for oxygen concentrator provided July 13, 2021, to October 13, 
2021. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal of an intact left breast implant (19328) provided 
on September 1, 2022. 
 
You asked the Plan to pay for the removal of an intact left breast implant. You say that you had a mammogram 
and one of your breast implants ruptured. You say that you needed to have them removed to avoid serious 
health issues. You say that you had to have both taken out or have a new one put in, so you chose to remove 
both. The Plan denied your request. The Plan says there is no evidence that the left implant was ruptured or 
damage, and therefore this portion of the procedure is non-covered as cosmetic. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
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 removal of an intact left breast implant. 
Our reviewer says that the criteria for coverage have not been met. Our reviewer found the record indicates that 
you had a contralateral ruptured implant.  The implants were placed for cosmetic reasons.  The record does not 
indicate that the requested procedure is being performed for the prompt repair of accidental injury or to 
improve the functioning of a malformed body member.  The record does not indicate that you had a condition 
that supports the medical necessity of the service in dispute. 
 
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 removal of an intact left breast implant have not been met. Therefore, we 
decided that the Plan does not have to pay for the removal of an intact left breast implant (19328) provided on 
September 1, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Axolotl and Celera (Q4259 x 80 and Q4210 x 80). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the medical studies have not proven this service/item is helpful for the 
treatment of the enrollee's health problem. 
 
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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the clinical value and effectiveness of Axolotl Graft in combination with Celera in the setting of chronic diabetic ulcer has not been demonstrated. The review has determined that the items/services at issue in 
this case are 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Axolotl and Celera (Q4259 x 80 and Q4210 x 80).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services billed for date of service August 30, 
2021. 
 
You asked the Plan to pay for home health services. You say that the services at issue have been billed 
correctly. The Plan denied your request. The Plan says rules for payment for home health services have not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that certain data elements are required for home 
health services. Any claim with incomplete, missing, or invalid information for all of these elements may be 
returned as unprocessable.   
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of home health services have not been met. Specifically, the provided records do not include a plan of 
care for the home health services at issue. Therefore, we decided that the Plan does not have to pay for home 
health services billed for date of service August 30, 2021.
Appeal type: Drugs
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 this drug is medically necessary. The Plan denied 
your request. The Plan says a trial of Infed or Venofer is required before alternatives can be considered. 
 
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 
Injectafer is not medically necessary. Our physician reviewer found the records show no trial of the plan 
preferred drugs, or any reason they would be unsafe or ineffective. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure (64628). 
 
You asked the Plan to pre-approve an Intracept procedure. 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 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 an Intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the magnetic resonance imaging (MRI) scan shows disc herniations and 
foraminal stenosis. The cause of the enrollee's back pain is not clear. 
 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure (64628).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for a segmental pneumatic appliance for use with pneumatic compressor, 
full leg (E0667) and segmental gradient pressure pneumatic appliance, half leg (E0673) provided November 1, 
2022. 
 
You asked the Plan to pay for the pneumatic appliances. You say that this equipment was ordered for this 
enrollee based on their high-risk level. The Plan denied your request. The Plan says that this service is denied 
because the claim for the related service has not been received or allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that PCD related accessories (E0655, E0656, E0657, 
E0660, E0665, E0666, E0667, E0668, E0669, E0670, E0671, E0672, E0673) are eligible for reimbursement 
only when the appropriate, related base PCDs (E0650, E0651, E0652, E0675) meets the applicable coverage 
criteria for that type of PCD.  
 
We looked at the file and Medicare rules. The records show that the Plan had approved payment of $242.55 for 
the related base PCD on January 5, 2023. Since the base has been approved then per Medicare rules, the related 
accessories are eligible for reimbursement. Based on this information, we decided that Medicare rules for 
coverage of the pneumatic appliances have been met. Therefore, we decided that the Plan has to pay for a 
segmental pneumatic appliance for use with pneumatic compressor, full leg (E0667) and segmental gradient 
pressure pneumatic appliance, half leg (E0673) provided November 1, 2022.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 4, 2022, to 
January 28, 2022. 
 
You asked the Plan to pay for the home health services as billed. The Plan denied your request. The Plan says 
the claim has not been billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from January 4, 2022, to 
January 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided the Plan does not have to pay for periodontal maintenance (D4910) provided on September 26, 2022.
You asked the Plan to pay for these dental services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says your benefit for the requested item or service has already been exhausted. Maximus overturned the Plans denial for insufficient claim information in the case file. The Plan requested a reopen and provided documentation to show that at the time of service, your benefit for periodontal maintenance had indeed been exhausted per the claims submitted by your dental providers.
The Plan is correct in this case. 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 this type of dental service was exhausted prior to this date of service. Therefore, we decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on September 26, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate and a KINEX allograft. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found there is no specific indication provided 
to support the request for bone marrow aspirate for the approved surgery. There is a lack of large-volume, long-
term peer-reviewed outcome studies to support the use of bone marrow aspirate for this enrollees medical condition as discussed above. There is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. Therefore, the requested bone marrow aspirate is 
not medically reasonable or necessary. 
 
There is limited published, large-scale, long-term peer-reviewed literature that shows this requested allograft to 
be an effective and/or safe treatment for the noted pathology. Further studies are needed to demonstrate this 
request has beneficial outcomes compared with conventional treatment. There is no compelling rationale 
presented or extenuating circumstances noted to support the medical necessity of this request as an exception. 
Therefore, the requested KINEX allograft 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve bone marrow aspirate and a KINEX allograft.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office visit provided on 
January 17, 2023. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that these charges should be 
a part of the surgical fee. 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 $45 
copayment for each in-network Medicare-covered visit with a specialist.  
 
 You have been asked to pay a $45 copayment for the specialist office visit. This item/service falls within the 
physician/practitioner services, including doctors office visits benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for the specialist office visit provided on January 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) at a third level. 
 
You asked the Plan to pre-approve RFA at a third level. You say that you have received this procedure 
numerous times in the past ever six to eight months. You say that you need sedation for this as it is extremely 
painful. You also say that you do not have a high pain tolerance. The Plan denied your request. The Plan says 
the requested injections and sedation are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that one to two levels, either unilateral or bilateral, are 
allowed per session per spine region. 
 
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 RFA at the third level. Our reviewer 
says that radiofrequency ablation (RFA) at a third level is not medically necessary. Our physician reviewer 
found that there is insufficient documentation to determine the need for a three or four-level procedure 
bilaterally. Therefore, the reviewer found that the RFA at a third level 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 RFA at the third level have not been met. Therefore, we decided that the Plan 
does not have to pre-approve radiofrequency ablation (RFA) at a third level.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transcatheter placement of an extracranial vertebral 
artery stent (0075T). 
 
You asked the Plan to pre-approve a transcatheter placement of an extracranial vertebral artery stent. 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 experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a transcatheter placement of an 
extracranial vertebral artery stent. Our reviewer says that the requested services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found that, based on the medical records 
provided and review of the current peer-reviewed medical literature, there is no documentation that the requested procedure at issue in this case meets all Medicare criteria for medically reasonable and necessary and 
safe and effective for the enrollee. The guidelines indicate that "endovascular techniques [for treatment of 
vertebral artery stenosis] are clinically feasible but have yet to deliver on durability benchmarks set by open 
surgical revascularization." 
 
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 transcatheter placement of an extracranial vertebral artery stent have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a transcatheter placement of an 
extracranial vertebral artery stent (0075T).