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

We decided that the Plan does not have to pre-approve a resin base maxillary partial denture (D5211).
You asked the Plan to pre-approve a resin base maxillary partial denture. You say that your provider advised
you to appeal 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 on date of service June 21, 2019. Therefore,
we decided that the Plan does not have to pre-approve a resin base maxillary partial denture (D5211).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electronic connection (E2311), expandable controller (E2377), and harness (E2313) for the enrollee.
You asked the Plan to pre-approve an electronic connection, expandable controller and harness. You say that these items are medically necessary. The Plan denied your request. The Plan says that the enrollee has adequate strength to control the power options with their own switches. Maximus overturned the Plan's denial. The Plan requested a reopening and stated that Maximus did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for an electronic connection, expandable controller and harness. Our Medical Director states that the clinical documentation in the case file does not sufficiently support that an electronic connection (E2311), expandable controller (E2377), and harness (E2313) were medically reasonable and necessary for the enrollee in this case.
Our Medical Director found that the enrollee's condition does not meet criteria for coverage of an electronic connection, expandable controller and harness. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of electronic connection, expandable controller and harness have not been met. Therefore, we decided that the Plan does not have to pre-approve an electronic connection (E2311), expandable controller (E2377), and harness (E2313) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on February 09, 2023. 
 
You asked the Plan to pay for lab testing. You say that you say this lab work should be covered. 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 lab testing provided on 
February 09, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Kerecis Omaga 3 skin substitute for the enrollee.
You asked the Plan to pre-approve Kerecis Omaga 3 skin substitute. You say that the skin substitute is
medically necessary. The Plan denied your request. The Plan says that the requested item is considered
experimental/investigational and is therefore non-covered. Maximus overturned the Plan's denial. The Plan
requested a reopening and stated that Maximus did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for Kerecis Omaga 3
skin substitute. Our Medical Director states that the documentation does not support that Kerecis Omaga 3 skin
substitute is medically reasonable and necessary for the enrollee in this case. The size of the wound, and the
failure of wound management are not sufficiently documented in the case file. Our physician reviewer found
that the enrollee's condition does not meet criteria for coverage of Kerecis Omaga 3 skin substitute.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Kerecis Omaga 3 skin substitute have not been met. Therefore, we decided that
the Plan does not have to pre-approve Kerecis Omaga 3 skin substitute for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an outpatient mental health visit provided on January 10, 
2023. 
 
You asked the Plan to pay for an outpatient mental health visit. You say that the records attached support the 
services provided. 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 an outpatient mental 
health visit provided on January 10, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance image (MRI) 
provided on March 03, 2023. 
 
You asked the Plan to waive the copayment for a magnetic resonance image (MRI). You say that you are not 
sure why the provider ordered an MRI when they are aware you have metal in your knee from a replacement. 
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 $300 
copayment for outpatient diagnostic test. 
 
You have been asked to pay a $300 copayment for a magnetic resonance image (MRI). This item/service falls 
within the outpatient diagnostic test 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. The total you owe is $222.55, which is less than the standard $300 copayment 
for an MRI. Therefore, we decided that the Plan does not have to waive the copayment for a magnetic 
resonance image (MRI) provided on March 03, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve in-office kyphoplasty at level L1. 
 
You asked the Plan to pre-approve in-office kyphoplasty at level L1. You say that the patient still has pain 
despite conservative treatment The Plan denied your request. The Plan says in-office kyphoplasty at level L1 is 
not medically reasonable and necessary because the patient does not meet coverage criteria. The Plan has 
approved T12 kyphoplasty. However, criteria for L1 are not met because there is no evidence of worsening 
pain at the L1 level. 
 
The Plan follows Medicare rules. Medicare rules say that kyphoplasty is coverable when medically necessary 
in accordance with the rules above. 
 
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 in-office kyphoplasty at level L1. Our 
reviewer says that in-office kyphoplasty at level L1 is not considered medically necessary in this case.  Our 
physician reviewer found there is magnetic resonance imaging evidence that the L1 fracture is less than 6 
weeks old and is an acute fracture. Therefore, this procedure would not be appropriate. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of in-office kyphoplasty at level L1 have not been met. Therefore, we decided that 
the Plan does not have to pre-approve in-office kyphoplasty at level L1.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each physical therapy (PT) visit provided 
on November 01, 2022, to November 30, 2022. 
 
You asked the Plan to waive the copayment for each physical therapy (PT) visit. You say that you were advised 
you would not have a copayment for the therapy services received. 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 $20 
copayment for outpatient rehabilitation services. 
 
You have been asked to pay a $20 copayment for each physical therapy (PT) visit. This item/service falls 
within the outpatient rehabilitation services 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 each physical therapy (PT) visit provided on November 01, 2022, to November 30, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CT scan provided on January 09, 2023. 
 
You asked the Plan to pay for CT scan. You say that you are requesting reconsideration for the services 
provided. 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 CT scan provided on 
January 09, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory drug testing provided on February 09, 2023. 
 
You asked the Plan to pay for laboratory drug testing. You say that this drug testing is medically necessary and 
should be covered. 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 laboratory drug testing 
provided on February 09, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a medication injection provided on May 26, 2022. 
 
You asked the Plan to pay for a medication injection. You say that this was medically necessary and should be 
covered. 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 a medication injection 
provided on May 26, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided on March 4, 2022, to March 11, 2022, at the Diagnosis Related Group (DRG) originally billed.
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that you disagree with the denial and the claim should be reconsidered. The Plan denied your request. The Plan says that principal diagnosis code A41.9 is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. Our Medical director looked at the case file and the reopen request. At issue is payment for inpatient hospital services at the DRG originally billed. In this case, you billed the inpatient services provided with principal diagnosis code A41.9 defined as Sepsis, unspecified organism. Our Medical Director states that the enrollee has a medical history that included hypertension and Gastroesophageal reflux disease (GERD). He presented to the hospital on 3/4/2022 with fever, weakness, difficulty walking, and confusion. Initially the enrollee was documented to be in no acute distress. Subsequently the enrollee was noted to be somnolent but arousable, and oriented only to self. Mild tenderness in the upper abdomen was documented. Laboratory studies were notable for leukocytosis, INR = 1.4, DBili = 0.6. A computed tomography (CT) scan demonstrated pericholecystic fluid and some pancreatic inflammation. The enrollee was diagnosed with cholecystitis with fever, weakness, and sepsis. IV antibiotics were administered. Open cholecystectomy with drain was performed on 3/5/2022. Endoscopic retrograde cholangiopancreatography (ERCP) with stent placement on 3/7/2022 for bile leak. The enrollee was discharged from the hospital on 3/11/2022 with a Principle Problem of Acute cholecystitis. The documentation supports Acute cholecystitis as the principal diagnosis for the enrollee in this case. Our Medical Director found that the enrollee's condition did not meet Medicare criteria for the inpatient hospital services provided from March 4, 2022, through March 11, 2022, at the DRG originally billed. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient hospital services provided on March 4, 2022, to March 11, 2022, at the Diagnosis Related Group (DRG) originally billed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar/sacral facets joint injections.  
 
You asked the Plan to pre-approve lumbar/sacral facets joint injections. You say that lumbar/sacral facets joint 
injections are medically necessary. The Plan denied your request. The Plan says the requested lumbar/sacral 
facets joint injections do not meet the Medicare LCD coverage criteria.  
 
The Plan follows Medicare rules.  
 
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 lumbar/sacral facets joint injections. 
Our reviewer says that the requested lumbar/sacral facets joint injections are not considered medically 
necessary in this case. Our physician reviewer found in this case, the enrollee has radiculopathy. The requested 
lumbar/sacral facet joint injections do not meet the Medicare LCD coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lumbar/sacral facets joint injections have not been met. Therefore, we decided 
that the Plan does not have to pre-approve lumbar/sacral facets joint injections.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code J3490 provided on February 22, 2023. 
 
You asked the Plan to pay for procedure code J3490. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the billed code is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code J3490 is not supported in the medical record. Specifically, this service is included in the 
global surgery package of code 64493 which was billed on the same claim. Based on this information, we 
decided that Medicare rules for coverage of procedure code J3490 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure code J3490 provided on February 22, 2023.
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 care was
medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria were not met.
Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the
correct criteria. The Plan noted that the review shows no mention of or reference to the pain limitation of
therapy that was mentioned by the in-hospital physical and occupational therapists that questioned the
enrollee's ability to perform therapy at the usual and customary 3 hours per day for 5 days per week at an
inpatient level of care expected at an IRF.
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 meet all the required coverage criteria for
admission to an IRF facility. Medicare rules for coverage of IRF care have not been 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on November 10, 2022. 
 
You asked the Plan to pay for an office visit. You say that this was medically necessary and should be covered. 
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 an office visit provided 
on November 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter (K0800). 
 
You asked the Plan to pre-approve a power scooter. You say that you disagree with the denial. The Plan denied 
your request. The Plan says that no face-to-face evaluation has been performed. 
 
The Plan must follow Medicare rules. Medicare rules say that a face-to-face encounter must be conducted 
within six months prior to the order date on the written order prior to delivery for the power mobility device 
and must contain the pertinent information listed in the LCD. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a power scooter have not been met. The record does not show that a face-to-face evaluation has 
been performed to access your mobility needs. Therefore, we decided that the Plan does not have to pre-
approve a power scooter (K0800).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network ambulance ride provided on 
October 25, 2022. 
 
You asked the Plan to waive the copayment for an in-network ambulance ride. You say that you were told by 
the hospital that they would pay for this service and they have not. 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 $265 
copayment for ambulance services. 
 
You have been asked to pay a $265 copayment for an in-network ambulance ride. This item/service falls within 
the ambulance services 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 an in-
network ambulance ride provided on October 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (K0849) and a transit 
securement package (K0108). 
 
You asked the Plan to pre-approve a power wheelchair and transit package. You say that you are requesting 
reconsideration of the denied authorization. The Plan denied your request. The Plan says that the enrollee does not have a qualifying diagnosis for a Group 3 power wheelchair. The Plan also says that a transit package is not 
needed for in home use. 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to a neurological condition, myopathy, or congenital 
skeletal deformity. The rules also say that Medicare will pay for durable medical equipment that is needed for 
use in the home. 
 
The file does not show that the enrollee has a mobility limitation that is due to a neurological condition, 
myopathy or congenital skeletal deformity. The requested transit securement package is not covered as it is not 
needed for use inside the home. Therefore, we decided that the Plan does not have to pre-approve a Group 3 
power wheelchair (K0849) and a transit securement package (K0108).