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

We decided that the Plan does not have to pre-approve an Accu-Chek meter and test strips.

You asked the Plan to pre-approve an Accu-Chek meter and test strips. The Plan denied your request. The Plan
says only the preferred brand products listed in the EOC are covered. Maximus overturned the Plan's denial
because of a lack of information. The Plan requested a reopening and indicated your provider has not indicated
why you cannot use their preferred products. The Plan is correct in this case. The Plan has shown that they
have faxed and called your physician for records. The Plan has not received a response and there is no rationale
as to why you are unable to use the Plan's preferred diabetic testing supplies.

The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including
non-preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations
associated with receipt or use of benefits.

We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand
for glucose monitors and test strips. Therefore, we decided that the Plan does not have to pre-approve an Accu-
Chek meter and test strips.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve infliximab. 
 You asked the Plan to pre-approve the medication. You say that the records provided support medical 
necessity. The Plan denied your request. The Plan says the enrollee has not tried and failed preferred 
medications. 
 
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. 
 
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 medication. Our reviewer says that 
the requested medication does not meet the requirements for step therapy guidelines. Our physician reviewer 
found it is documented that a trial of Renflexis was less effective for the enrollee. However, the case file does 
not contain documentation of trial and failure of Inflectra. Documentation does not support that Inflectra 
would likely be less effective and/or would likely have adverse effects for the enrollee 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 the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve infliximab.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve methotrexate. 
 
You asked the Plan to pre-approve the medication. You say that the requested medication would be beneficial 
to the enrollee. 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 methotrexate.  
 
Benefits for the medication 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99284 billed for date of service July 28, 
2023. 
 You asked the Plan to pay for procedure code 99284. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 99284 is bundled into payment for code 99285. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 99284 
is a column II code to column I code 99285. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 99284 billed for date of service July 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) for tooth #9. 
 
You asked the Plan to pre-approve the dental service. You say that your previous crown never set right because 
of the gaps that were left so a new crown is necessary. 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 the Plan paid for a crown (D2740) for tooth #9 on December 15, 2021; therefore, your benefit for the 
requested item or service was exhausted on the date of service of December 15, 2021. Therefore, we decided 
that the Plan does not have to pre-approve a crown (D2740) for tooth #9.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intracept procedure. 
 
You asked the Plan to pre-approve the intracept procedure. You say that the enrollee has tried and failed 
conservative treatments without relief. The Plan denied your request. The Plan says the intracept procedure 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 intracept procedure. Our reviewer 
says that the intracept procedure is not medically necessary. Our physician reviewer found that there is no 
magnetic resonance imaging (MRI) showing only modic changes with facet degenerative joint disease, and the 
cause of pain is not clear. 
 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 intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the intracept procedure.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vertiflex Superion. 
 
You asked the Plan to pre-approve Vertiflex Superion. You say that the enrollee requires the use of the 
requested procedure to help increase the space between their backbones. The Plan denied your request. The 
Plan says the requested procedure does not meet the criteria for approval. 
 
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 Vertiflex Superion. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the vertiflex spacer is experimental. More research is needed to show safety and 
efficacy. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vertiflex Superion have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Vertiflex Superion.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement graft for ridge preservation-for tooth 
number 19 (D7953). 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the requested service is 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 service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a bone 
replacement graft for ridge preservation-for tooth number 19 (D7953).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a routine comprehensive exam provided on October 3, 2023. 
 
You asked the Plan to pay for the exam. You say that this was a regular gynecology visit, and not a physical. 
The Plan denied your request. The Plan says you had a routine exam within the last 24 months. 
 
The Plan must follow Medicare rules. Medicare rules say that Pap tests and pelvic exams are covered once 
every 24 months.  
 
We looked at the file and Medicare rules. The file shows that you had a previous exam done on September 27, 
2022. Based on this information, we decided that Medicare rules for coverage of the exam have not been met. 
Therefore, we decided that the Plan does not have to pay for a routine comprehensive exam provided on 
October 3, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (CGM) (A4239) provided on 
August 22, 2023. 
 
You asked the Plan to pay for the CGM. You say that the items should be covered as you disagree with the 
denial. 
 The Plan denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 The record does not contain a valid physician order, or relevant medical records which support medical 
necessity for the supplies provided in this case. There are no orders documented in the medical records for a 
Continuous Glucose Monitor (CGM) device or supplies. The record shows that the Plan made several attempts 
to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to 
pay for a continuous glucose monitor (CGM) (A4239) provided on August 22, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vertiflex Superion. 
 
You asked the Plan to pre-approve Vertiflex Superion. You say that you require the procedure to help the 
nerves in your hips and legs. The Plan denied your request. The Plan says the requested procedure is unproven 
and 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 Vertiflex Superion. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the vertiflex spacer is experimental. More research is needed to show safety and 
efficacy. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vertiflex Superion have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Vertiflex Superion.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the detailed and extensive problem focused 
evaluation (D0160) provided on October 3, 2023. 
 
You asked the Plan to reimburse you for the evaluation provided on October 3, 2023. You say that you do not 
have any other coverage. You also say that you should be reimbursed $425. The Plan denied your request. The 
Plan says your benefit for the requested item or service has already been exhausted. 

 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service July 20, 2023. Therefore, 
we decided that the Plan does not have to reimburse you for the detailed and extensive problem focused 
evaluation (D0160) provided on October 3, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you need the SNF services to fully regain 
independence. The Plan denied your request. The Plan says the SNF services are 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 there are no identifiable skilled nursing service needs. There are identifiable skilled 
therapy service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet 
severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the adjunctive pre-diagnostic test that aids 
in the detection of mucosal abnormalities (D0431) provided on March 28, 2023. 
 
You asked the Plan to issue reimbursement for this service. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says this service is 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 service provided is not among 
those covered under this benefit.   
 
Therefore, we decided that the Plan does not have to issue reimbursement for the adjunctive pre-diagnostic test 
that aids in the detection of mucosal abnormalities (D0431) provided on March 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the complete series x-ray (D0210) provided on 
September 22, 2023. 
 
You asked the Plan to pay more for the complete series x-ray. You say that you found this provider's name on 
the Plan's website. You say that the provider has not updated their address yet. You also say that this should be 
covered. The Plan denied your request. The Plan says there is 20% coinsurance for the complete series x-ray. 
 
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 and this service is listed as covered, 
there is a 20% coinsurance that applies to this service. This is a contractual obligation you agreed to when you 
enrolled in the Plan's dental coverage. Therefore, we decided that the Plan does not have to pay more for the 
complete series x-ray (D0210) provided on September 22, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 36415, 80053, 80061, 82306, 82728, 83036, 
& 85025 provided on February 20, 2023. 
 
You asked the Plan to pay for procedure codes 36415, 80053, 80061, 82306, 82728, 83036, & 85025. You say 
that these services were medically necessary. The Plan denied your request. The Plan says the claim cannot be 
paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that payment for Professional Component (PC) 
Services Payment may be made under the physician fee schedule for the professional component of physician 
laboratory or physician pathology services furnished to hospital inpatients or outpatients by hospital physicians 
or by independent laboratories. 
 
We looked at the file and Medicare rules. The billed services are not found on the physician fee schedule. 
Based on this information, we decided that Medicare rules for coverage of procedure codes 36415, 80053, 80061, 82306, 82728, 83036, & 85025 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure codes 36415, 80053, 80061, 82306, 82728, 83036, & 85025 provided on February 20, 2023.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a spinal cord stimulator trial (63655, 63685) to
include implantation of a permanent electrode for the enrollee.

You asked the Plan to provide coverage for a spinal cord stimulator trial (63655 and 63685) to include
implantation of a permanent electrode. The Plan denied your request. The Plan says the spinal cord stimulator
trial was approved; however, the implantation of the permanent electrode cannot be approved until the spinal
cord stimulator trial is complete and the documentation shows permanent placement meets the required
coverage criteria. Maximus overturned the Plans denial. The Plan requested a reopen and noted that Maximus
did not apply the correct criteria.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that implantation of a
permanent electrode is approved after the spinal code stimulator trial is performed and the enrollee shows at
least a 50% reduction of target pain, or 50% reduction of analgesic medications, and show some element of
functional improvement. Clearly these criteria cannot be met prior to implantation therefore implantation of a
permanent electrode at the same time there is implantation of the trial device cannot be covered. Therefore, we
decided that the Plan does not have to provide coverage for a spinal cord stimulator trial (63655 and 63685) for
the enrollee.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for the air ambulance transport from Iowa Methodist Medical Center to 
University of Iowa Hospital provided on April 27, 2023. 
 
You asked the Plan to pay for air ambulance transport. You say that your services were requested and 
medically necessary. The Plan denied your request. The Plan says that the information provided at the time of 
the appeal does not support criteria for an air ambulance transport. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 pay for the air ambulance transport. Our reviewer 
says that the air ambulance services provided on April 27, 2023, were medically necessary. Our physician 
reviewer found that according to the documentation provided, the services need to treat the enrollee were not 
available at the sending hospital. Although the enrollee was stable for ground transfer, the enrollee was 
transferred via air ambulance as there were no ground units available. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of air ambulance transport have been met. Therefore, we decided that the Plan has 
to pay for the air ambulance transport from Iowa Methodist Medical Center to University of Iowa Hospital 
provided on April 27, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a medical eye exam, and ophthalmic diagnostic imaging 
provided on March 07, 2023. 
 
You asked the Plan to pay for a medical eye exam, and ophthalmic diagnostic imaging. You say that the 
provider was unaware that they were out-of-network. The Plan denied your request. The Plan says that 
unauthorized, out-of-network care is not covered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The 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(s)/service(s) at issue. We found no exception that 
would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to 
pay for a medical eye exam, and ophthalmic diagnostic imaging provided on March 07, 2023.