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

We decided that the Plan does not have to pay for the limited oral evaluation and cone beam computed
tomography (CT) capture rendered on April 7, 2023.

You asked the Plan to pay for these services. You say that you would not deliberately go to an out-of-network
provider. The Plan denied your request. The Plan says the 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 Plan's 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.

The previous determination stated that the Plan had to pay for the limited oral evaluation because the contract
says that the services are 100 percent covered; however, this coverage is for the optional supplemental dental
benefit in which you are not enrolled. The standard dental benefit with the Plan does not cover the limited oral
evaluation or the cone beam CT capture. Therefore, we decided that the Plan does not have to pay for the
limited oral evaluation and cone beam computed tomography (CT) capture rendered on April 7, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rytary. 
 
You asked the Plan to pre-approve Rytary. You say that the medication is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Rytary.  Benefits for Rytary may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for medical services (G2012) provided to the enrollee on January 16,
2023.

You asked the Plan to pay this claim. The Plan denied your request. The Plan says the Medicare billing criteria
were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did
not apply the correct criteria. The Plan demonstrated Place of Service (POS) 10 is telehealth provided in
patient's home. It is the location where health services and health related services are provided or received,
through telecommunication technology. The patient is in their home (which is a location other than a hospital
or other facility where the patient receives care in a private residence) when receiving health services or health
related services through telecommunication technology. Per the Medicare guidelines and the List of Medicare
Telehealth Services effective January 1, 2023, procedure code G2012 is not listed and therefore not
payable when billed with POS 10.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. Providers must report services with the appropriate code. In this case, the Plan has
demonstrated that code G2012 cannot be billed with a POS code of 10. Medicare rules for payment of this
service have not been met Therefore, we decided that the Plan does not have to pay for medical services
(G2012) provided to the enrollee on January 16, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a Vacuum Assisted Socket System (VASS).

You asked the Plan to provide coverage for a Vacuum Assisted Socket System (VASS). You say that a
Vacuum Assisted Socket System (VASS) is medically necessary. The Plan denied your request. The Plan says
a Vacuum Assisted Socket System (VASS) is not covered by Medicare.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered. Based on the medical records provided, the documentation in the reopen request
does not support that a VASS (L5981) is medically reasonable and necessary in this case. Medicare rules for
coverage of this item have not been met. Therefore, we decided that the Plan does not have to provide coverage
for a Vacuum Assisted Socket System (VASS).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF)
admission and services for the enrollee.

You asked the Plan to provide coverage for IRF care. You say that at the time of the appeal IRF admission was
medically necessary. The Plan denied your request. The Plan says the 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. The Plan noted that the medical records show the enrollee requires maximum assistance with
activities of daily living, medication, transfers and ambulates with a rolling walker. It was not expected that the
enrollee would have the ability to participate in an IRF level of care.

The Plan is correct in this case. 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.
Based on the medical records provided, the enrollee did not require daily skilled nursing and daily skilled
therapy services at an inpatient IRF level of care. It also was not expected that the enrollee would be able to
participate in at least 3 hours a day for 5 days a week at an IRF level of care. Medicare rules for coverage were
of IRF admission were not met. Therefore, we decided that the Plan does not have to provide coverage for
acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (code 83880) provided on May 17, 2023. 
 
You asked the Plan to pay for the lab services. You say that physicians send specimens for testing. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 

The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. The claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services (code 83880) provided on May 17, 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 the enrollee needs more therapy before returning 
home. The Plan denied your request. The Plan says IRF criteria are not met.  
 
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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are 
stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for 
physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary 
rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an IRF.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a qualified speech-language pathologist in the home 
health or hospice setting (G0153x4). 
 You asked the Plan to pre-approve home health services. You say that you are requesting reconsideration and 
have submitted medical records for review. The Plan denied your request. The Plan says the services are not 
medically 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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found that clinical 
documentation does not show any acute functional status change including dysphagia or new cognitive 
impairments and instruction on home exercise plan has been provided. The records do not show that for home 
health speech therapy visits are required to effectively provide treatment, care, and/or services in order to 
improve the enrollee's level of function, or to establish/perform a maintenance program to maintain the 
enrollee's level of function and/or prevent deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a qualified speech-language pathologist in the home health or hospice setting 
(G0153x4).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires an IRF admission. The Plan 
denied your request. The Plan says the enrollee's condition does not meet the requirements for an IRF 
admission.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xanax. 
 
You asked the Plan to pre-approve Xanax. You say that the medication is medically necessary. The Plan denied 
your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Xanax.  Benefits for Xanax may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve NGS Myeloid Neoplasm panel or Acute Myeloid Disorder 
Leukemia Panel. 
 
You asked the Plan to pre-approve a myeloid disorder panel. You say that the services are necessary. The Plan 
denied your request. The Plan says that based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that testing for myeloid malignancies and suspected 
myeloid malignancies is covered when specific criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a myeloid disorder panel. Our reviewer 
says that the services are medically necessary. Our physician reviewer found the enrollee has acute myeloid 
leukemia and thus the testing is medically necessary and meets criteria outlined for coverage. 
 
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 myeloid disorder panel have been met. Therefore, we decided that the Plan 
has to pre-approve NGS Myeloid Neoplasm panel or Acute Myeloid Disorder Leukemia Panel.  
 
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 bathtub wall rail, a toilet rail, and a bathtub floor rail. 
 
You asked the Plan to pre-approve a bathtub wall rail, toilet rail, and a bathtub floor rail. You say that the 
enrollee's safety is at risk due to declined endurance. The Plan denied your request. The Plan says these items 
are not primarily medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The items at issue in this appeal do not serve a purpose that is primarily medical in nature. These items are 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a bathtub wall rail, a toilet rail, and a bathtub floor rail.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve the home ventilator. You say that the enrollee has chronic COPD with 
multiple hospitalizations. The Plan denied your request. The Plan says a home ventilator is not medically 
necessary for the enrollee because their needs can be met with an alternative device such as a BiPAP device 
with average volume-assured pressure support (AVAPS).  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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 home ventilator. Our reviewer says 
that the home ventilator is not medically necessary. Our physician reviewer found the enrollee has severe 
COPD/asthma overlap, obstructive sleep apnea, class III obesity, and obesity hypoventilation syndrome. An 
arterial blood gas on October 25, 2023 was consistent with chronic carbon dioxide (CO2) retention, with a 
partial pressure of carbon dioxide (PaCO2) of 56. There is a history of noncompliance with both CPAP and a 
home ventilator. The enrollee may benefit from BiPAP with AVAPAS during sleep if compliance can be 
achieved. Medicare does not cover a home ventilator when used at settings that can be provided with BiPAP. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cozaar (losartan) tablets. 
 
You asked the Plan to pre-approve the medication. You say that you need this medication, and you have been 
out of your prescription for over two weeks. The Plan denied your request. The Plan says the medication is not 
covered as a medical benefit under the Plan. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Cozaar (losartan) tablets.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a prosthetic leg with an electronic knee feature
(L5828, L5845, L5848, L5850, L5856).

You asked the Plan to provide coverage for this prosthetic equipment. The Plan denied your request. The Plan
says the 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. The Plan noted that no objective clinical
documentation was provided to show the need of a microprocessor knee over a mechanical knee. The notes do
not show why a mechanical K3 knee will not meet the enrollee's ambulation needs. The description of
enrollee's activity level fits the definition of a K3 but does not explain why a microprocessor knee is medically
necessary.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that items and
services that are not medically necessary are not covered. Medicare does not provide coverage for prosthetic
equipment that exceeds the enrollee's ambulation needs. The medical records show not support the need for a
microprocessor knee over a mechanical knee. Medicare rules for coverage of this prosthetic equipment have
not been met. Therefore, we decided that the Plan does not have to provide coverage for a prosthetic leg with
an electronic knee feature (L5828, L5845, L5848, L5850, L5856).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76942-26-XU provided July 12, 2023. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is not covered as billed.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, we have confirmed that code 76942 is a column II code to column I code 64454; however, 76942 
was billed with a modifier.  
 
We asked our coder 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 service. Our reviewer found the documentation submitted 
was reviewed and does not meet criteria. The medical record describes Genicular block performed with 
ultrasound. Per CPT code description "including imaging guidance". In this case, the procedure report does not 
include documentation to support ultrasonic guidance for needle placement as an unusual non-overlapping 
service, and therefore, the procedure code and modifier cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 76942-26-XU provided July 12, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Capsaicin (Qutenza) 8% patch, per square centimeter 
(J7336). 
 You asked the Plan to pre-approve Qutenza kit. You say that you have tried Gabapentin in the past, but you had 
to stop taking it due to it affecting you vision. The Plan denied your request. The Plan says the step therapy 
criteria has not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Qutenza kit. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Plan requires a trial of drug of gabapentin or pregabalin and one tricyclic antidepressant 
(such as nortriptyline or desipramine) before they will approve the requested drug. In this case, the enrollee has 
not tried and failed the required drug(s). There is no documentation provided indicating that the Plans required 
drug(s) would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Qutenza kit have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Capsaicin (Qutenza) 8% patch, per square centimeter (J7336).