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

 
We decided that the Plan does not have to pay for a walker purchased on Amazon on June 30, 2020. 
 
You asked the Plan to pay for a walker purchased online from a provider who is not Medicare eligible. You say 
that the Plan should pay for this walker. The Plan denied your request. The Plan says Amazon.com is not a 
Medicare eligible provider. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a provided who is not a Medicare eligible provider. Amazon.com is 
not a Medicare eligible provider. Therefore, we decided that the Plan does not have to pay for a walker 
purchased on Amazon on June 30, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a colonoscopy provided on August 13, 
2020. 
 
You asked the Plan to waive the copayment for a colonoscopy. You say that you should not owe a copayment 
for preventative services. The Plan denied your request. The Plan says the claims were processed correctly and 
you are being charged the correct amount. 
 
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 $200 
copayment for outpatient surgery provided in an outpatient hospital facility.  
 
The medical records show that you had polyps removed during a colonoscopy on August 13, 2020. Therefore, 
the colonoscopy is considered diagnostic, not preventative, and you are responsible to pay the $200 copayment.  
 
You have been asked to pay a $200 copayment for a colonoscopy. A colonoscopy falls within the outpatient 
hospital 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 copayment for a colonoscopy 
provided on August 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on November 5, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are 
available in-network. 
 
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 has network providers 
available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at 
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that 
the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider 
on November 5, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the policy requires 80% relief of pain from test blocks. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the criteria is 80% or better pain relief from each of the medial branch blocks. This threshold was not 
met, and therefore, the request is considered not medically reasonable or 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve radiofrequency ablation.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on May 29, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the drug testing services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
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 has network providers 
available who can provide 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 drug testing services provided on May 29, 
2020 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive this copayment.  
 
You asked the Plan to waive the copayment for ambulance transport. You say that you do not believe you 
should have to pay this copayment. The Plan denied your request. The Plan says this copayment was charged 
based on the services provided and the Plan contract agreement. 
 
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 $200 
copayment for ambulance transport. 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 copayment charged for ambulance transport 
provided on July 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the comprehensive eye exam (92014) 
provided August 13, 2020. 
 
You asked the Plan to waive the copayment for the vision services. You say that the exams were not medical, 
but routine for an established patient. You believe these claims were incorrect and misrepresented the services 
provided. Your responsibility should only be $15. The Plan denied your request. The Plan says the claim was 
processed and the correct copayment was applied per the plan benefits. 
 
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 $25 for 
each Medicare-covered outpatient visit for services to diagnose and/or treat a disease or condition of the eye.  
 
You have been asked to pay $25 for the vision services. The vision services fall within the Vision care 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 copayment for the comprehensive eye exam (92014) provided 
August 13, 2020.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pre-approve Myeloproliferative Neoplasm External Reflex Panel. 
 
You asked the Plan to pre-approve Myeloproliferative Neoplasm External Reflex Panel. You say that you 
would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the requested 
testing is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Myeloproliferative Neoplasm External Reflex Panel 
testing is covered for certain indications. 
 
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 Myeloproliferative Neoplasm External 
Reflex Panel. Our reviewer says that the documentation does support that the requested testing is medically 
reasonable and necessary. Our physician reviewer found the enrollee has persistent thrombocytosis since 2018. 
here is concern for a possible underlying primary bone marrow disorder, including Essential (hemorrhagic) 
thrombocythemia. The enrollee's hematologist writes that step-wise testing (first JAK2 V617F with reflex exon 
12 testing, followed by CALR and MPL testing if the first testing was negative) would be okay. LCD L36180 
states that coverage for the genetic testing at issue is provided when a sequential genetic testing approach is 
utilized, and the genetic testing would impact medical management. The Myeloproliferative Neoplasm 
External Reflex Panel includes qualitative detection of JAK2 V617F, JAK2 Exon 12-14, CALR exon 9, and 
MPL exon 10. Testing proceeds by reflex through the four-step panel until a mutation is identified, when the 
result is considered informative and no further testing is performed. Therefore, the enrollee meets criteria for 
the requested testing. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Myeloproliferative Neoplasm External Reflex Panel have been met. Therefore, 
we decided that the Plan has to pre-approve Myeloproliferative Neoplasm External Reflex Panel.  
 
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 admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the services can be safely received in other settings, for example: a skilled nursing 
facility, home with home health services, or home with outpatient therapy. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 based on the medical records provided the complexity of the enrollee's nursing, 
medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. The enrollee does require physical therapy and occupational therapy services 
but based on the medical records provided the enrollee does not require an intensive inpatient rehabilitation 
therapy program. Care at the skilled nursing facility level appears to be more appropriate 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from November 28, 2019 to 
December 2, 2019. 
 
You asked the Plan to pay for the acute inpatient hospital care. You say that the enrollee was appropriate for 
inpatient admission. The Plan denied your request. The Plan says that the enrollee did not require two 
midnights of hospital care and could have been managed in outpatient observation status. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the enrollee was a male with end-stage renal disease on dialysis with a history of 
deep vein blood clot. He was admitted due to pain at the dialysis access site. He was found to have vascular 
stenosis and possible chronic thrombus in the superior vena cava. He was treated with IV Vancomycin, 
anticoagulants, and continued dialysis. He was to continue IV Vancomycin for 10 days. The review indicates 
that the record showed that at the time of inpatient admission the admitting physician reasonably expected that 
the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights. 
 
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 acute inpatient hospital care have been met. Therefore, we decided that the 
Plan has to pay for the acute inpatient hospital care provided from November 28, 2019 to December 2, 2019.  
 
 
 
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: Favorable

 
We decided that the Plan has to pay for hearing aid check (92592) provided on August 11, 2020. 
 
You asked the Plan to pay for hearing aid check. You say that the service should be covered. The Plan denied 
your request. The Plan says that this is not a covered service. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan pays for one 
aid per ear, per year. The price of the hearing aid(s) include the following: pre-fitting hearing aid evaluation 
appointment, cost of the hearing aid, fitting of the hearing aid device (including programming, verification 
measures), up to two follow-up visits in the first 12 months after purchase. 
 
We looked at this physician's review, the file, and the Plan's rules. Based on this information, we decided that 
the Plan's rules for coverage of hearing aid check have been met. The record does not show that you exhausted 
your benefit of two follow up visits for hearing aids in the 2020 calendar year. The record also does not 
disclose on what date you purchased your hearing aid(s). Therefore, we decided that the Plan has to pay for 
hearing aid check (92592) provided on August 11, 2020.  
 
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: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a continuous glucose monitor with supplies for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the enrollee is not having to make frequent insulin treatment regime changes. 
 
The Plan must follow Medicare rules. Medicare rules say that services are covered if 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 the services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee is on sliding scale insulin three times daily, and is therefore frequently adjusting insulin 
dosage based on readings. Due to complicated diabetes, the enrollee would more likely benefit from tighter 
glucose control. 
 
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 services have been met. Therefore, we decided that the Plan has to pre-
approve a continuous glucose monitor with supplies for the enrollee.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardiovascular risk assessment testing provided to the 
enrollee on April 23, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says cardiovascular risk assessment testing is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare does not cover cardiovascular risk 
assessment testing. Medicare rules for coverage of this service have not been met. Therefore, we decided that 
the Plan does not have to pay for cardiovascular risk assessment testing provided to the enrollee on April 23, 
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the consultation (D9310) provided on August 5, 2020. 
 
You asked the Plan to pay for the dental service. You say that you requested a list of in network oral surgeons 
prior to your appointment. You say that the provider you saw was on the list of in network providers that you 
received from the Plan. You say that when you called the dental office you were advised that the provider does 
not participate with Medicare. You say that you should be reimbursed for the service as you were given 
incorrect information from the Plan. The Plan denied your request. The Plan says the provider in this case has 
opted out Medicare. The Plan says that payments cannot be made for dental services that you receive from a 
provider who has opted out of Medicare. The Plan also says that the consultation is not listed as a covered 
service. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care.  
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. The record shows that you were advised by a plan representative of 
providers that were in network and that you should contact the provider's office directly to verify that the 
provider's status had not changed. Additionally, though the Plan offers a dental benefit in excess of Medicare 
coverage, the consultation is not among those covered under this benefit. Therefore, we decided that the Plan 
does not have to pay for the consultation (D9310) provided on August 5, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan does not have to pre-approve Keytruda for the enrollee.
You asked the Plan to pre-approve Keytruda. You say that Keytruda is medically necessary for the enrollee.
The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the
Plans denial. The Plan requested a reopen and stated Maximus applied the incorrect criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for Keytruda.
The Maximus Physician Reviewer determined that Keytruda is FDA-approved for the enrollee's diagnosis of
transitional cell carcinoma of the ureter and renal pelvis, but only as a single agent and not in combination.
The Plan requested a reopen stating the combination approved by Maximus was incorrect. The records show
the enrollee is a 62-year-old man with a diagnosis of AJCC Stage IV T3N1M1 Papillary carcinoma of the
ureter and renal pelvis with pulmonary nodules. In view of progression of the enrollee's disease, and the
multiple lines of treatment, the provider requested approval of Enfortumab and Keytruda. However, the plan is
correct in this case. The request was for coverage of Keytruda to be used in conjunction with Enfortumab
Vedotin-ejfv. Approval of Keytruda as a single agent in this case was incorrect. Medicare coverage criteria
were not met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan
does not have to pre-approve Keytruda for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental extraction to be provided by an oral surgeon. 
 
You asked the Plan to pre-approve a dental extraction to be provided by an oral surgeon. You say that you 
would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested 
services are not a covered benefit. 
 
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. You are requesting a dental extraction to be provided by an oral 
surgeon. While the plan does cover one dental extraction per year, the plan only covers these services when 
provided by a participating general dentist. Therefore, we decided that the Plan does not have to pre-approve a 
dental extraction to be provided by an oral surgeon.