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

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the heart with 
quantitative evaluation of coronary calcium (75571).  
 
You asked the Plan to pre-approve a CT scan with quantitative evaluation of coronary calcium. You say that 
you are requesting an expedited appeal due to medical necessity. The Plan denied your request. The Plan says 
the request is not medically reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 a CT scan with quantitative evaluation 
of coronary calcium. Our reviewer says that the service is not medically necessary. Our physician reviewer 
found you have no cardiac symptoms but were noted to have coronary calcification on a CT scan of the chest. 
The record provided is insufficient to establish the medical necessity of the requested service as defined by 
Medicare rules. The elements of the coverage criteria are not satisfied. The requested service cannot be 
recommended. 
 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 CT scan with quantitative evaluation of coronary calcium have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the 
heart with quantitative evaluation of coronary calcium (75571).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a Monovisc injection (code J7327) for the
enrollee.

You asked the Plan to provide coverage this injection. The Plan denied your request. The Plan says the medical
records do not show the enrollee has tried and failed or is unable to be treated with Euflexxa. Maximus
overturned the Plans denial for a lack of medical records in the file. The Plan requested a reopen and provided
the required medical records.

The Plan is correct in this case. 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. Based on the medical records provided, the enrollee has not tried
and failed Euflexxa. Therefore, we decided that the Plan does not have to provide coverage a Monovisc
injection (code J7327) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an electronic connection (E2311), harness (E2313), and 
expandable controller (E2377). 
 
You asked the Plan to pre-approve an electronic connection, harness, and expandable controller. You say that 
the electronics are medically necessary to provide the enrollee with the most independence with pressure relief 
possible. The Plan denied your request. The Plan says that the electronic connection, harness, and expandable 
controller cannot be covered as it is not medically necessary to control the three approved power options 
through the joystick (drive interface). 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 an electronic connection, harness, and 
expandable controller. Our reviewer says that the requested items/services are considered medically reasonable 
and necessary in this case. Our physician reviewer found the enrollee is non-ambulatory and requires a power 
wheelchair for mobility and performing daily activities. They cannot perform pressure relief independently due 
to upper extremity weakness and require a power wheelchair with power tilt and recline for adequate pressure 
relief and positioning. There is a history of skin breakdown. Our reviewer found that power elevating leg rests 
are required for positioning of the lower extremities and lower extremity spasticity. The complexity of the 
enrollees seating and positioning needs necessitates a more complex group 3 power wheelchair base. The 
expandable controller with harness and electronic connection are necessary to operate the group 3 power 
wheelchair base and the three power options via a joystick. Our physician reviewer also found that these 
components are required to operate 3 or more power options on a group 3 power wheelchair. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an electronic connection, harness, and expandable controller have been met. 
Therefore, we decided that the Plan has to pre-approve an electronic connection (E2311), harness (E2313), and 
expandable controller (E2377).  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance without transport services provided on June 
16, 2023. 
 
You asked the Plan to pay for the ambulance without transport services. You say that the enrollee's vital signs 
had returned to normal once the paramedics arrived and there was no need to be transported to the emergency 
room. The Plan denied your request. The Plan says the Medicare ambulance benefit is a transportation benefit 
and without a transport there is no payable service. 
 
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 16, 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 without transport services provided 
on June 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for maxillary partial denture (D5225) provided on March 14, 
2023. 
 
You asked the Plan to pay for the dental services. You say that this 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 13, 2020. 
Therefore, we decided that the Plan does not have to pay for maxillary partial denture (D5225) provided on 
March 14, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance without transport services received on 
February 18, 2023. 
 
You asked the Plan to pay for the ambulance without transport services. You say that you were not feeling well 
and were checked over and decided to hold off on going to the hospital. The Plan denied your request. The Plan 
says without transport there is no payable service. 
 
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 February 18, 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 without transport services received 
on February 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral - periapical each additional radiographic image 
(D0230) provided on July 13, 2023. 
 
You asked the Plan to pay for the dental services. You say that this 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. Therefore, we decided that the Plan does 
not have to pay for intraoral - periapical each additional radiographic image (D0230) provided on July 13, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a flex-walk system (L5981) and a multi-axial rotation
unit (L5986) for the enrollee.

You asked the Plan to pre-approve a flex-walk system and a multi-axial rotation unit. You say that the
requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says that the
requested items are not medically necessary.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for a flex-walk system
and a multi-axial rotation unit. Our Medical Director states that the limited clinical documentation does not
support that the enrollee in this case has a functional level of 2 or above. Our Medical Director found that the
enrollee's condition does not meet criteria for coverage of a flex-walk system and a multi-axial rotation unit.

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 flex-walk system and a multi-axial rotation unit have not been met. Therefore,
we decided that the Plan does not have to pre-approve a flex-walk system (L5981) and a multi-axial rotation
unit (L5986) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rocklatan. 
 
You asked the Plan to pre-approve Rocklatan. You say that the patient has been well controlled with the 
addition of Rocklatan to Cosopt and Brimonidine. 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 Rocklatan.  
 
Benefits for Rocklatan 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a retreatment of previous root canal therapy - molar 
(D3348). 
 
You asked the Plan to pre-approve the retreatment of previous root canal therapy - molar. You say that you 
were referred to and endodontist due to an infection in tooth #'s 18 and 19. You also say that you were 
informed that the antibiotics did not clear up the infection and you need a re-do on the root canal. The Plan 
denied your request. The Plan says dental billing codes D334, D3347 and D3348 are not listed as covered 
dental services. 
 
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 a 
retreatment of previous root canal therapy - molar (D3348).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the chemotherapy treatments to be provided by an OON 
provider.  
 
You asked the Plan to pre-approve the chemotherapy treatments. You say that you are requesting 
reconsideration of the denied services. The Plan denied your request. The Plan says the service was not 
approved. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the chemotherapy treatments to be provided by an OON provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for codes 99214, 14021, 17313, and 17000 billed for date of service 
December 8, 2022. 
 
You asked the Plan to pay for 99214, 14021, 17313, and 17000. You say that 99214, 14021, 17313, and 17000 
should be paid as billed because they are supported in the record and have not been previously paid. The Plan 
denied your request. The Plan says that this claim is a duplicate of a previously paid claim and was correctly 
denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. We find that the file does not include sufficient evidence to support 
the Plans argument that the claim at issue is a duplicate. The case file indicates that a claim for the services 
provided on December 8, 2022, was first billed to another insurance company, which initially did process the 
claim for payment, but it also includes proof that this other insurance company retracted their payment for 
these services. The case file contains documentation that the other insurance company confirmed receipt of a 
refund from the provider for the services performed on December 8, 2022, as of July 17, 2023. Based on this 
information, we decided that Medicare rules for coverage of 99214, 14021, 17313, and 17000 have been met. 
Therefore, we decided that the Plan has to pay for codes 99214, 14021, 17313, and 17000 billed for date of 
service December 8, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has 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 interdisciplinary approach to 
meet the goal of returning home modified independently. The Plan denied your request. The Plan says the IRF 
services requested do not meet the requirements for approval. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the medical record overall significantly complies with the various documentation requirements for an 
IRF admission, as best summarized by the physical therapy note from October 28, 2023 and the occupational 
therapy note from October 30, 2023. The enrollee's condition is complex and fragile, and there is every reason 
to expect that they will participate in and benefit from IRF-level services to include at minimum physical and 
occupational therapy for pre-prosthetic training, physician oversight of wound care and polypharmacy, and 
case manager coordination of the additional services that will be needed to make a sustainable return home, as 
well as avoid preventable readmissions to the acute hospital. Therefore, the requested inpatient rehabilitation 
facility admission is approved. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: 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 and can tolerate three hours of 
therapy a day provided by a multidisciplinary team. You say that the enrollee requires physical therapy to work 
on increasing strength, endurance, functional mobility, durable medical equipment management, gait, transfers 
safety, balance and stairs. The Plan denied your request. The Plan says an IRF admission is not medically 
necessary.  
 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 that the enrollee does not need physician supervision 3 times a week or intensive 
therapy 3 hours a day and 5 days per week with a multidisciplinary approach in an IRF. While the enrollee may 
benefit from physical and occupational therapy the enrollee's needs can be provided in an alternate setting such 
as skilled nursing facility.  
 
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: Favorable

 
We decided that the Plan has to waive the copayment for a crown (D2740) provided on May 22, 2023. 
 
You asked the Plan to waive the copayment for the dental service. You say that you are being overcharged by 
the provider. The Plan denied your request. The Plan says that the denial is correct based on the lack of 
available medical records. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan did not collect dental records, an itemized bill, or treatment 
records from their participating provider who completed the dental service. Participating providers are 
considered agents of the Plan. Without this necessary documentation we are unable to make a determination as 
to whether the enrollee has properly been charged the correct amount for the dental services. Phone call dates 
requesting the records is not an acceptable substitution for dental records, an itemized bill, or treatment records. 
Therefore, we decided that the Plan has to waive the copayment for a crown (D2740) provided on May 22, 
2023.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral  comprehensive series of radiographic images 
(D0210), and comprehensive oral evaluation - new or established patient (D0150) provided on August 21, 
2023. 
 
You asked the Plan to pay for the dental services. You say that the benefit maximums should not apply as you 
received the services in dispute from a different provider than where the previous services were rendered. The 
Plan denied your request. The Plan says your benefit for the requested services 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 intraoral  comprehensive series of radiographic images was exhausted on date of 
service December 21, 2021, and the comprehensive oral evaluation was exhausted on dates of service January 
30, 2023 and February 8, 2023. Therefore, we decided that the Plan does not have to pay for an intraoral  
comprehensive series of radiographic images (D0210), and comprehensive oral evaluation - new or established 
patient (D0150) provided on August 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on June 17, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your $1,000 annual maximum 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 $1,000 annual maximum was exhausted. Therefore, we decided that the Plan does not have to pay 
for dental services provided on June 17, 2023.