Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 power wheelchair (PWC) (K0823). 
 
You asked the Plan to pre-approve a group 2 PWC. You say that the item is medically necessary. The Plan 
denied your request. The Plan says the records do not show that a home assessment, to ensure there is enough 
room in the enrollee's home to use the power wheelchair, was completed. 
 
The Plan must follow Medicare rules. Medicare rules say that the enrollees home must provide adequate 
access between rooms, maneuvering space, and surfaces for the operation of the power wheelchair for it to be 
covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a group 2 PWC have not been met. Therefore, we decided that the Plan does not have to pre-
approve a group 2 power wheelchair (PWC) (K0823).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator system.  
 
You asked the Plan to pre-approve a home ventilator system. You say that due to the enrollee's state of chronic 
respiratory failure, severe restriction related to their morbid obesity, need for advanced ventilation and chronic 
carbon dioxide retention, the enrollee was ordered non-invasive ventilatory therapy to use at home to better 
manage their carbon dioxide retention and provide respiratory support for exertional distress in the daytime. The Plan denied your request. The Plan says a home ventilator is not medically necessary for this patient 
because their needs can be met with an alternative device such as a BiPAP device with average volume-assured 
pressure support (AVAPS).  
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator system. Our reviewer 
says that a home ventilator system is not medically necessary. Our physician reviewer found that the enrollee 
has severe obesity and obesity hypoventilation syndrome. The enrollee also was recently hospitalized, and 
arterial blood gases were consistent with chronic carbon dioxide retention. However, there is no diagnosis of 
COPD, thoracic restrictive disease, or neuromuscular disease. The enrollee also may benefit from a BiPAP 
during sleep as an outpatient, which has not been tried and failed. Furthermore, the AVAPS mode of support, if 
considered necessary can be delivered with a BiPAP. Therefore, a home ventilator is 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 a home ventilator system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a home ventilator system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator system. 
 
  You asked the Plan to pre-approve a home ventilator system. You say that the enrollee has already tried and 
failed BiPAP titration. You say that due to the enrollee failing BiPAP titration they were prescribed a non-
invasive ventilator for the management of both COPD and severe obstructive sleep apnea. The Plan denied 
your request. The Plan says a home ventilator is not medically necessary for this patient because their needs 
can be met with an alternative device such as a BiPAP device with average volume-assured pressure support 
(AVAPS).  
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator system. Our reviewer 
says that a home ventilator system is not medically necessary. Our physician reviewer found that the enrollee 
has severe COPD and obstructive sleep apnea. While a BiPAP effectively reduced the obstructive events, the 
enrollee remained hypoxic despite supplemental oxygen. Also, the enrollee reportedly has had a home 
ventilator previously but was noncompliant. Also, there was no trial of a BiPAP with ASV or AVAPS. 
Furthermore, the enrollee may benefit from a BiPAP with AVAPS-AE during sleep as an outpatient if 
compliance can be achieved. Therefore, a home ventilator is 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 a home ventilator system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a home ventilator system.
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's needs cannot be safely met by skilled 
nursing or home health at this time as he requires direct physician supervision and management. The Plan 
denied your request. The Plan says the enrollee does not meet the requirements for an IRF admission.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. There is not a reasonable expectation that the enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. Medically necessary care can 
be provided in a different 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for  ER services and pay for self-administered 
drugs provided on May 21, 2023, to May 22, 2023. 
 
You asked the Plan to waive the copayment for  ER services and pay for self-administered drugs. You say that 
this was medically necessary and should be covered. The Plan denied your request. The Plan says this cost 
sharing was charged correctly and self-administered drugs are not covered. 
 
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 $90 
copayment for emergency care and self-administered drugs are not covered. 
 
You have been asked to pay $90 copayment for ER services. The ER services falls within the emergency care 
benefit category. In addition, you are responsible for the full cost of the self-administered drugs as they are not 
covered. 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. Self-administered 
drugs are not covered Therefore, we decided that the Plan does not have to waive the copayment for  
emergency room (ER) services and pay for self-administered drugs provided on May 21, 2023, to May 22, 
2023.  
 
Benefits for self-administered drugs 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Venofer injection. 
 
You asked the Plan to pre-approve Venofer injection. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the requested drug is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that parenteral iron in iron deficiency anemia is covered 
when oral supplementation has been tried and the patient has demonstrated significant gastrointestinal distress 
whereas compliance with an oral regimen is no longer feasible. 
 
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 Venofer injection. Our reviewer says 
that the documentation does not support that the requested drug is medically reasonable or necessary. Our 
physician reviewer found the enrollee has iron deficiency anemia in the setting of chronic kidney disease not 
requiring dialysis. The record does not document the failure of oral iron. The record does not indicate that the 
enrollee has an enumerated condition for which coverage is available under the rules. Therefore, the enrollee 
does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Venofer injection have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Venofer injection.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CT scan of the thorax. 
 
You asked the Plan to pre-approve a CT scan of the thorax. You say that that the CT scan can hopefully give 
you a piece of mind that the 11-mm lipoma is still unchanged. The Plan denied your request. The Plan says a 
CT scan of the thorax is not medically 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 of the thorax. Our reviewer 
says that a CT scan of the thorax is not medically necessary. Our physician reviewer found that you have a 
history of lipoma resection. However, the records provided is insufficient to establish the medical necessity of 
the requested service at this time. Also, the provided records do not indicate the medical necessity or 
reasonableness, as defined by Medicare rules, of the requested service. Therefore, the elements of the coverage 
criteria are not satisfied, and 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 of the thorax have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CT scan of the thorax.
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 would like SNF services. The Plan denied your 
request. The Plan says you do not meet the requirements for a SNF admission. 
 
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 the medical records provided show your past level of function is supervision level 
with mobility and self-care tasks. The clinical documentation does not specify any daily skilled nursing needs 
thus daily skilled services are not supported. Therefore, the medical documentation provided does not support 
the medical necessity of daily skilled services on an inpatient basis in an SNF. 
 
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: 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 will require a multi-
disciplinary approach for an extended period. The Plan denied your request. The Plan says the records do not 
show that the enrollee needs continued treatments and care that can only be given in a hospital 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 the enrollee does not require services at the LTACH that are not available at the acute 
care hospital. There are no services available at the LTACH that the enrollee requires that are not available at 
the health care setting being offered by the health plan. Given there are offered alternatives, LTACH is 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 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: 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 the enrollee is not a surgical 
candidate for knee surgery due to multiple comorbidities. The Plan denied your request. The Plan says this 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 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 the record indicates that the enrollee has right knee pain. There is 
insufficient literature to support the safety and efficacy, as defined by Medicare rules, of the requested service. 
The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arthrodesis, sacroiliac joint, percutaneous or minimally 
invasive (27279). 
 
You asked the Plan to pre-approve sacroiliac joint fusion. You say that you are requesting reconsideration due 
to medical necessity. The Plan denied your request. The Plan says the records show that the enrollee has an 
alternative or contributing diagnosis that could be considered a possible cause of her pain. The request 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 sacroiliac joint fusion. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has a history of chronic lower back pain. A February 3, 2020, magnetic 
resonance imaging (MRI), the enrollee had an MRI which showed broad based posterior herniation of L5-S1, 
causing mild narrowing of the central canal and neural foramina bilaterally. The enrollee has failed 
conservative measures dating back to 2019, including oral medications, physical therapy, chiropractic care, and 
warm and cool compresses. The enrollee has another probable pain generator, the herniated disc that needs to 
be addressed as this may confuse the diagnosis. At this time, the request is considered 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 sacroiliac joint fusion have not been met. Therefore, we decided that the Plan 
does not have to pre-approve arthrodesis, sacroiliac joint, percutaneous or minimally invasive (27279).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from
January 9, 2023, to January 12, 2023.

You asked the Plan to pay for the home health services. You say that this claim was billed with the correct
Type of Bill code. The Plan denied your request. The Plan says that you billed with an incorrect type of bill
code. Maximus overturned the Plan's denial. The Plan requested a reopening based on the fact the claim was
submitted with the incorrect type of bill code. The Plan was correct in this case, the claim was not filed with the
correct type of bill code.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the home health services have not been met. Therefore, we decided that the Plan does not have to
pay for the home health services provided to the enrollee from January 9, 2023, to January 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an unspecified periodontal procedure (D4999) provided on 
July 24, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental 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. 
 
 
  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 an 
unspecified periodontal procedure (D4999) provided on July 24, 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 needs the genicular 
nerve block in preparation for a radiofrequency ablation.  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 enrollee 
has osteoarthritis of the knee. However, there is insufficient literature to support the safety and efficacy, as 
defined by Medicare rules of the requested service. Also, the records provided does not establish the medical 
necessity and reasonableness, as defined by Medicare rules, of the requested service. Therefore, the elements of 
the coverage criteria are not satisfied, and the requested service is not 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 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chronic care management services (99490, 99439) 
provided on June 30, 2023, by an OON provider.  
 
You asked the Plan to pay for the chronic care management services (99490, 99439). You say that you are 
appealing the claim payment denial. The Plan denied your request. The Plan says the services were provided 
out-of-network, however there were in-network providers with the time and distance standards set forth by 
Medicare. 
  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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. 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 chronic care management services (99490, 
99439) provided on June 30, 2023, by an OON provider.