Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a leadless pacemaker. 
 
You asked the Plan to pre-approve a leadless pacemaker. The Plan denied your request. The Plan says a 
leadless pacemaker is not covered by Medicare.  
 
"The Plan follows Medicare rules. Medicare rules say that Medicare covers leadless pacemakers through 
Coverage with Evidence Development (CED). CMS covers leadless pacemakers when procedures are 
performed in Food and Drug Administration (FDA) approved studies. 
 
  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 leadless pacemaker. Our reviewer 
says that a leadless pacemaker is not medically necessary. Our physician reviewer found that you have a 
history if persistent arterial fibrillation with bradycardia However, there is no documentation of symptomatic 
bradycardia. While, atrioventricular (AV) node ablation is contemplated after pacemaker, there is no 
documentation of uncontrolled, rapid ventricular rates. Furthermore, there is insufficient documentation to 
support the medical necessity for the insertion of a leadless pacemaker in your clinical management. 
 
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 leadless pacemaker have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a leadless pacemaker.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the eyewear (codes V2020, V2781, V2784, and 
V2797) purchased on September 30, 2023. 
 
You asked the Plan to pay more for the eyewear. You say that the manager told you they were in-network the 
day you ordered the glasses. The Plan denied your request. The Plan says this claim has processed correctly. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers a $100 benefit toward the purchase and fitting of eyeglasses and pair of lenses or 
contact lenses once per calendar year. The contract also says that you are responsible for any amount over the 
$100 retail price. 
 
 We looked at the file and the Plan's rules. The record shows that the retail price/submitted charge for the 
eyewear is $279.85. After deducting the $100.00 allowance, $179.85 remains as your responsibility.  Based on 
this information, we decided that the Plan's rules for coverage of the eyewear have not been met. Therefore, we 
decided that the Plan does not have to pay more for the eyewear (codes V2020, V2781, V2784, and V2797) 
purchased on September 30, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Minuteman procedure. 
 
You asked the Plan to pre-approve the Minuteman procedure. You say that this is medically necessary. The 
Plan denied your request. The Plan says there are not enough studies on Minuteman procedure to show it is 
safe and effective. Therefore, it not considered standard of care. 
 
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 Minuteman procedure. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found current evidence-based medical guidelines and peer-reviewed literature do 
not fully support the interspinous fusion device procedure over the gold standard of lumbar fusion. There is a 
lack of large-volume, long-term peer-reviewed outcome studies to support the use of this device for this 
enrollees medical condition. In addition, fusion indications within guidelines/literature for (existing or 
potential intraoperative) instability have not been documented and/or met in this case. In addition, there are 
multiple alternate pain generators plausibly significantly contributing to the clinical condition that have not 
been fully documented as having been excluded and/or ruled out. The enrollee is a current smoker. No 
compelling rationale is 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 the Minuteman procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Minuteman procedure.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 22, 2023, to 
April 19, 2023. 
 
You asked the Plan to pay for the home health services as billed. You say that you are appealing this denial. 
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 March 22, 2023, to April 
19, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vivaer procedure. 
 
You asked the Plan to pre-approve Vivaer procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says the criteria for reasonable and necessary are not met as this device has not been 
shown to be safe and effective for treatment of your condition. 
 
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 Vivaer procedure. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is insufficient literature to support the safety and efficacy of the requested 
service for the enrollee's specific conditions. The record provided does not establish medical necessity and 
reasonableness.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vivaer procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Vivaer procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation-problem focused (D0140) and an 
extraction (D7210) provided on August 18, 2023. 
 
You asked the Plan to pay for the dental services. You say that the Plan paid part of the claim but not all. You 
say your dentist is in-network and you should have been covered. The Plan denied your request. The Plan says 
these services are not covered. 
 
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. Therefore, we decided that the Plan does not have to pay for a limited 
oral evaluation-problem focused (D0140) and an extraction (D7210) provided on August 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99070 billed for date of service October 18, 
2023. 
 
You asked the Plan to pay for procedure code 99070. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says procedure code 99070 is considered bundled and 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 procedure code. 
 
We find that procedure code 99070 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99070 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99070 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99070 billed for date of service October 18, 2023.
Appeal type: Imaging
Decision: Unfavorable

We decided the Plan does not have to pay for imaging services provided to the enrollee on February 2, 2023.

You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says the enrollee was incarcerated at the time of services. Maximus overturned the Plans
denial for insufficient information in the case file. The Plan requested a reopen and submitted additional
information.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare does pay for services provided
to incarcerated enrollees. We have confirmed the enrollee was incarcerated on the date of service. Therefore,
we decided that the Plan does not have to pay for imaging services provided to the enrollee on February 2,
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that  the enrollee needs this level of care. The 
Plan denied your request. The Plan says the enrollees medical condition does not require LTACH services, 
and care can be provided in current setting.  
 
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 medical records do not support that the enrollee's condition would improve with this 
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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a car hitch (E1399). 
 
You asked the Plan to pre-approve a care hitch. You say that you need this item. The Plan denied your request. 
The Plan says this item does not serve a medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
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 car hitch (E1399).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and replace missing or 
broken teeth - complete denture (D5520) provided on August 22, 2023. 
 
You asked the Plan to pay for the dental services. You say that you thought the services would be covered. 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 Plans 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 April 13, 2023. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) and replace 
missing or broken teeth - complete denture (D5520) provided on August 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on 
September 18, 2023. 
 
You asked the Plan to pay for the dental services. You say that this service should be covered. 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 Plans 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 October 25, 2022. 
Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) 
provided on September 18, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for a continuous glucose monitor 
(CGM) provided on August 3, 2023. 
 
You asked the Plan to pay for the supply allowance for a CGM. You say that you have submitted all the 
relevant documents, including proof of delivery and other supporting documents to fulfill your obligations. 
You also say that you request that the claim be reprocessed and paid. The Plan denied your request. The Plan 
says the provider is not enrolled in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
 
 Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the supply allowance for a continuous 
glucose monitor (CGM) provided on August 3, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).  
You asked the Plan to pre-approve a CGM. You say that this should be covered. The Plan denied your request. 
The Plan says the medical criteria for a CGM have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not have an in-
person visit with their treating physician to evaluate their diabetes control and to determine whether the criteria 
for coverage have been met.  Based on this information, we decided that Medicare rules for coverage of a CGM 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose 
monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for periodontal scaling and root planing 
(D4341) provided on July 18, 2023. 
 
You asked the Plan to waive the coinsurance for D4341. You say that you feel like you are being overcharged. 
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 30% 
coinsurance for dental services/restorative & extraction services.  
 
You have been asked to pay a 30% coinsurance for D4341. This item/service falls within the dental 
services/restorative & extraction 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 coinsurance 
for periodontal scaling and root planing (D4341) provided on July 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on May 18, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the office visit. You say that the physician works in the office with the enrollee's 
primary care physician. The Plan denied your request. The Plan says these services were not urgent or 
emergent, nor were they approved in advance. 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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) The Plan did not pre-approve the item/service at issue. We found no exception that would 
require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for 
the office visit provided on May 18, 2023, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for a continuous glucose monitor 
(CGM) provided on July 31, 2023. 
 
You asked the Plan to pay for the supply allowance for a CGM. You say that you have submitted all the 
relevant documents, including proof of delivery and other supporting documents to fulfill your obligations. 
You also say that you request that the claim be reprocessed and paid. The Plan denied your request. The Plan 
says the provider is not enrolled in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the supply allowance for a continuous 
glucose monitor (CGM) provided on July 31, 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 meets the criteria for admission to the 
IRF and will benefit from the IRF services that cannot be accomplished at a lower level of care. The Plan 
denied your request. The Plan says the enrollee's medical and therapy needs could be met in a skilled nursing 
facility.  
 
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 enrollees nursing, medical, and rehabilitation needs does not 
require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program. The enrollee continues to have a need for skilled 
therapy with ongoing safety concerns and a potential for functional improvement. However, the documentation 
does not support that the enrollee would meet criteria for admission to an IRF.  There is no indication that the 
enrollee would require skilled rehabilitation in an IRF, participating in rehabilitation services 15 hours a week, 
under the supervision of a physician with at least 3 visits weekly to regain or maintain their functional 
status.  The enrollee can receive further services 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames (V2020), purchased on September 20, 2022. 
 
You asked the Plan to pay for the frames. You say that the item was medically necessary. The Plan denied your 
request. The Plan says the is not a covered item.  
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear.  
 
The services you asked the Plan to pay for are considered routine vision services or eyewear. Therefore, we 
decided that the Plan does not have to pay for the frames (V2020), purchased on September 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction (D7210) and evaluation (D0140). 
 
You asked the Plan to pay for the dental services. You say that the services should be covered. The Plan denied 
your request. The Plan says your benefit for the evaluation has already been exhausted and the cost share for 
the extraction has been applied correctly. 
 
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, certain limitations apply. The record 
shows your benefit for the evaluation was exhausted on date of service September 5, 2023, and therefore not covered. There is a 40% coinsurance for comprehensive dental services which applies to the extraction. 
Therefore, we decided that the Plan does not have to pay for the extraction (D7210) and evaluation (D0140).