Persius/hicric huggingface dataset:
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.

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 clearly show the enrollee's ability to participate in
intensive therapy was described as limited by the hospital physical therapist, given their decreased endurance
and strength.

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, it was not expected the enrollee would be able to participate in at least three
hours of therapy per day at least five days per week. 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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), bitewings (D0274), and a 
cleaning (D1110) provided by an out-of-network provider on May 31, 2023. 
 
You asked the Plan to pay for the dental services. You say that the provider told you that they take your 
insurance, and they are in-network. The Plan denied your request. The Plan says the dental services were 
received from an out-of-network provider and are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a periodic oral evaluation (D0120), bitewings (D0274), and a cleaning (D1110) provided by an out-
of-network provider on May 31, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 You asked the Plan to pre-approve Euflexxa. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that viscosupplementation therapy 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 Euflexxa. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found there is no imaging submitted with this 
request. Therefore, the request is deemed not medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tier exception for contour test strips (A4253). 
 
You asked the Plan to pre-approve a tier exception for contour test strips. You say that you are requesting this 
to be covered at a lower cost level. The Plan denied your request. The Plan says Tier exception reviews are 
NOT allowed under Part B. Tiering exceptions are only allowed for certain drugs covered under Medicare Part 
D.  
 
The Plan must follow Medicare rules. Medicare rules state that tiering exceptions cannot apply to Part B drugs. 
Tiering exceptions are only applicable to Part D drugs.  
 
We looked at the file and Medicare rules. The item(s) you are requesting is considered a Part B item. As a 
result, no tiering exceptions can be made. Therefore, we decided that the Plan does not have to pre-approve a 
tier exception for contour test strips (A4253).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 12 additional physical therapy (PT) visits.  
 
You asked the Plan to pre-approve the therapy services. You say that the additional PT visits are necessary for 
your recovery process. The Plan denied your request. The Plan says you do not meet the criteria of LCA 
A52775 for the additional PT visits.   
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 the therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found you have been receiving physical therapy since March 29, 2023. Your 
motor strength and range of motion are nearly normal, and you are independent with daily activities. You have 
been noted to hike several miles and kayak. You can continue with a home exercise program and do not require 
the services of a skilled therapist to perform strengthening and range of motion exercises.  Therefore, the 12 
additional PT visits are not medically 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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 12 additional physical therapy (PT) visits.
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for genetic testing provided to the enrollee.

You asked the Plan to pay for this testing. You say that this claim should be paid. The Plan denied your
request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial for
insufficient information in the case file. The Plan requested a reopen and noted that per the Palmetto GBA
DEX Diagnostic Exchange Registry: DEX Z-Code Z00D5 is a non-covered code for Medicare claims.
Therefore, the reported Z code is not valid.

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 codes. In this case, this claim
could not be paid as billed due to an error with the reported Z code. Therefore, we decided that the Plan does
not have to pay for genetic testing provided to the enrollee.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on June 25, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you were 
not hurt and that is why you did not go to the hospital. You also say that it would have cost more to the health 
plan if you did go to the hospital, and no one told you  it would not be covered if you did not go The Plan 
denied your request. The Plan says these services are not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on June 25, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on June 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the genicular nerve block. 
 
You asked the Plan to pre-approve the genicular nerve block. You say that the enrollee will benefit from the 
genicular nerve block. The Plan denied your request. The Plan says the genicular nerve block is not medically 
necessary.  
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the genicular nerve block. Our reviewer 
says that the genicular nerve block is not medically necessary. Our physician reviewer found that the genicular 
nerve block is the subject of ongoing clinical trials and is considered experimental and investigational. 
 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 genicular nerve block have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the genicular nerve block.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for supplies for maintenance of noninsulin drug infusion catheter 
(A4221) and infusion supplies not used with external infusion pump (A4223). 
 You asked the Plan to pay for Supplies for maintenance of noninsulin drug infusion catheter and infusion 
supplies not used with external infusion pump . You say that the items are medically necessary. The Plan 
denied your request. The Plan says Infusion pumps and associated supplies and drugs are not covered when the 
drug can be safely administered without an infusion pump. There is no documentation that the drug could not 
be safely administered without an infusion pump. A4223-Infusion supplies not used with external infusion 
pump, per cassette or bag (list drugs separately) is statutorily excluded. 
 
The Plan must follow Medicare rules. Medicare rules say that disposable drug delivery systems, including 
elastomeric infusion pumps are non-covered devices because they do not meet the Medicare definition of 
durable medical equipment. Drugs and supplies used with disposable drug delivery systems are also non-
covered items. Procedure codes with a status indicator of X are statutorily excluded. These codes represent an 
item or service that is not in the statutory definition of "physician services" for fee schedule payment purposes. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Supplies for maintenance of noninsulin drug infusion catheter and infusion supplies not used with 
external infusion pump have not been met. Therefore, we decided that the Plan does not have to pay for 
supplies for maintenance of noninsulin drug infusion catheter (A4221) and infusion supplies not used with 
external infusion pump (A4223).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve branch injections. 
 
You asked the Plan to pre-approve genicular nerve branch injections. You say that you have been in pain 24/7 
for over a year. It interrupts your sleep, how you walk, bend over, lift objects, and sitting for any length of time. 
You are in so much nerve pain. The Plan denied your request. The Plan says this does not meet the criteria for 
coverage. 
 
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 genicular nerve branch injections. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this is considered an experimental/ investigational procedure. It is the 
subject of ongoing clinical trials. Therefore, the request is deemed not medically reasonable and necessary.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genicular nerve branch injections have not been met. Therefore, we decided that 
the Plan does not have to pre-approve genicular nerve branch injections.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH level of care is the best option 
for a safe discharge due to the need for skilled nursing care, daily physician management, advanced wound 
care, nutritional optimization, frequent labs, along with daily physical therapy. The Plan denied your request. 
The Plan says an LTACH admission is not medically necessary.  
 
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 that the documentation does not support that LTACH services are medically 
appropriate. The enrollee is receiving the appropriate care in the current acute care setting as provided by the 
Health Plan. 
 
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 LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom fabricated abutment-includes placement 
(D6057) and an abutment supported porcelain/ceramic crown (D6058). 
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the requested items are not covered under the supplemental 
dental policy.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  
 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a custom 
fabricated abutment-includes placement (D6057) and an abutment supported porcelain/ceramic crown (D6058).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. The Plan denied your request. The Plan says the settings can be 
achieved using a BiPAP.  
 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 a ventilator. Our physician reviewer 
found that the enrollee has obstructive sleep apnea with chronic respiratory failure. The requested ventilator 
will be used as BIPAP. The enrollee improved with BIPAP therapy in hospital and does not have documented 
data to support home ventilator. Therefore, there is no indication for a home ventilator in this case.  
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve precision attachment (D5862x6). 
 
You asked the Plan to pre-approve precision attachment. You say that this should be covered. The Plan denied 
your request. The Plan says this is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
precision attachment (D5862x6).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MRI of the heart. 
 
You asked the Plan to pre-approve MRI of the heart. You say that this is medically necessary. The Plan denied 
your request. The Plan says there is no documentation of significant vascular disease that may require 
intervention. This is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
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 MRI of the heart. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found a cardiac MRI stress test, in a clinical 
setting and outside of a research protocol, is not a medical necessity in work up for ischemic heart disease and 
clearly not in the above individual with a normal stress echocardiogram. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MRI of the heart have not been met. Therefore, we decided that the Plan does 
not have to pre-approve MRI of the heart.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic tooth 19, 20 (D6240) and a retainer crown for 
tooth 18, 21 (D6750). 
 
You asked the Plan to pre-approve a pontic and retainer crowns. You say that this is medically necessary. The 
Plan denied your request. The Plan says this is not medically necessary. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers a pontic and 
retainer crowns when the services are medically necessary and reasonable.  
 
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 pontic and retainer crowns. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found based on the information required, there is not enough information to determine the medical necessity for replacing the 
bridge 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of a pontic and retainer crowns have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a pontic tooth 19, 20 (D6240) and a retainer crown for tooth 18, 21 (D6750).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that you can make more progress in rehab, but you need 
more time. You are not in position to be home alone. The Plan denied your request. The Plan says this is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found You do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the re-cement or re-bond crown (D2920) provided on 
June 16, 2023. We also decided that the Plan does not have to pay for the prefabricated post and core in 
addition to crown (D2954) provided on June 16, 2023. 
 
You asked the Plan to pay more for the re-cement or re-bond crown. You say that you found the name of the 
provider two years ago when you signed up for the policy. You also say that you do not feel responsible for 
this. The Plan denied your request. The Plan says you are responsible for any charged amount above the Plans 
cost-sharing amount when your services are received from an out-of-network provider.  
 The Plan also says the prefabricated post and core in addition to crown (D2954) is not a covered expense under 
your dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for the re-cement or re-bond crown (D2920) 
provided on June 16, 2023.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the prefabricated post and core in 
addition to crown is not among those covered under this benefit. Therefore, we decided that the Plan does not 
have to pay for the prefabricated post and core in addition to crown (D2954) provided on June 16, 2023