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

 
We decided that the Plan does not have to pay for a chest x-ray (CPT 71045) provided to the enrollee on March 
17, 2020. 
 
You asked the Plan to pay for the x-ray. You say that this should be paid for. The Plan denied your request. The 
Plan says in patients at risk for developing lung cancer, screening for lung cancer with chest x-ray once or at 
regular intervals is not recommended. 
 
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, the CPT Code Manual definition of code 71045 is "chest x-ray, one view." 
 
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 x-ray. Our reviewer says that the services 
at issue in this case were not supported by the medical records. Our physician reviewer found the given history 
of nicotine dependence is not an adequate indication for a single view chest x-ray. If this enrollee has an 
adequate smoking history, she would be eligible for a low dose lung CT for cancer screening which would have 
been a much more sensitive screening test than a chest x-ray. In particular, she is within the accepted age range 
(55-77) and would have qualified if her smoking history exceeds 30 pack years. In someone with a current 
nicotine dependence on would assume she is still smoking which would also have qualified her for a low dose 
CT. 
 
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 x-ray have not been met. Therefore, we decided that the Plan does not have 
to pay for a chest x-ray (CPT 71045) provided to the enrollee on March 17, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services.
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied
your request. The Plan says the services are 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 pay for the laboratory services. Our reviewer says
that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found per the review there is no documentation provided to indicate the clinical rationale or
medical necessity for the obtained tests. The review has determined that the services were 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 laboratory services have not been met. Therefore, we decided that the Plan
does not have to pay for the laboratory services.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to waive the copayment for the pulmonary function test provided on January 7, 
2020. 
 
You asked the Plan to waive the copayment for the pulmonary function test. You say that you were told you 
would only have a $25 copayment. The Plan denied your request. The Plan says that you have been charged the 
correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that covered services include other outpatient diagnostic tests.  
 
The Plan says you must pay a $225 for the pulmonary function test. Based on the Plan contract, however, you 
cannot be asked to pay more than a $0 for the pulmonary function test. The record shows that the pulmonary 
function test is considered a diagnostic test. This means that since there is no copayment listed for other 
outpatient diagnostic tests, we cannot determine the correct cost sharing amount. Therefore, we decided that the 
Plan has to waive the copayment for the pulmonary function test provided on January 7, 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: 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 services are medically necessary. The 
Plan denied your request. The Plan says the services are not medically necessary. 
 
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 services are not medically necessary. Our physician reviewer found the enrollee was admitted to the 
hospital with seizure activity and possible encephalitis. She was treated with antiviral medication and 
antiepileptic medications; however, she is in a coma. Currently she continues to require CPAP pressure support 
for weaning from mechanical ventilation. The enrollee does not require any services at the proposed LTACH 
that are not already available at the current facility. There are no services available at the LTACH that are not 
already available and covered at the current facility. The LTACH services are therefore not reasonable or 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that there is no clinical advantage of LTACH over acute hospital. 
 
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. The enrollee 
appears unstable for transfer at this time due to a new infection being treated, however, based on the clinical 
course, she will likely be stable enough to transfer to an appropriate lower level of care in less than 25 days. 
The enrollee does not require any services at the proposed LTACH that are not already available at the current 
facility. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 
services. 
 
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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the treatment of a root canal obstruction (D3331), endodontic therapy (D3320), and core buildup, including any pins when required (D2950) provided on March 31, 2020.
You asked the Plan to pay for the treatment of a root canal obstruction, endodontic therapy, and core buildup. You say that these services were performed in an emergency situation, outside of the waiting period. The Plan denied your request. The Plan says treatment of a root canal obstruction is not a covered benefit. The Plan also says that the 6 month waiting periods for endodontic therapy and core buildup applies for both emergency and non-emergency care, and no exceptions can be made for this rule.
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, treatment of a root canal obstruction (D3331) is not among those covered under this benefit. The contract shows that endodontic therapy (D3320) and core buildup, including any pins when required (D2950) are covered benefits, but you must wait 6 months after becoming eligible with the Dental PPO plan before you can receive these services and have them covered by the Plan. Therefore, we decided that the Plan does not have to pay for the treatment of a root canal obstruction (D3331), endodontic therapy (D3320), and core buildup, including any pins when required (D2950) provided on March 31, 2020.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the definitive lab testing provided on July 11, 2019. 
 
You asked the Plan to pay for the definitive lab testing. You say that all documents support that this was 
necessary testing. The Plan denied your request. The Plan says that the submitted Laboratory Requisition 
indicates that a ?Toxicology Profile R001? Panel was requested. The submitted documentation does not itemize 
what tests are included in this panel; therefore, the billed code cannot be verified. 
 
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. The Plan's denial rationale references a laboratory requisition form that was not 
included in the case file sent to MAXIMUS for review. As the Plan did not submit a complete case file 
including all documents that were used in making its decision, we find that the denial of payment in this case is 
not substantiated. Therefore, we decided that the Plan has to pay for the definitive lab testing provided on July 
11, 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia for the enrollee.
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered under Part B when self-administered.
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 Prolia for the enrollee.
Benefits for this drug 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 Euflexxa (J7323). 
 
You asked the Plan to pre-approve Euflexxa. You say that Euflexxa is medically necessary. The Plan denied 
your request. The Plan says a trial of Orthovisc and Monovisc is required before alternatives can be considered. 
 
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 Euflexxa. Our reviewer says that 
Euflexxa is not medically necessary. Our physician reviewer found the record shows the enrollee has trialed the 
plan preferred Monovisc, but has not trialed plan preferred agent Orthovisc. The record shows no reason 
Orthovisc would be unsafe or ineffective for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa (J7323).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an X-Ray examination provided on 
September 13, 2019. 
 
You asked the Plan to waive the deductible for X-Ray exam. You say that this charge seems excessive. The 
Plan denied your request. The Plan says the deductible amount you are being charged is correct. The Plan also 
says that they have reprocessed and paid this claim at the in-network rate, so you are only responsible for the 
in-network deductible cost-sharing. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $300 deductible for in-network X-Ray. At the time this claim was 
processed, $112.11 of the $300 deductible had been met. The allowed amount of the claim is $113.89, resulting 
in a deductible obligation of $113.89. 
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is $300 deductible for in-network X-Rays. This cost sharing is a contractual 
obligation that had not been met at the time X-Ray exam was received on September 13, 2019. Therefore, we 
decided that the Plan does not have to waive the deductible for an X-Ray examination provided on September 
13, 2019.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Zilretta. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says that the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise 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 these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the enrollee has significantly decreased 
knee pain for multiple months following a previous Zilretta injection. Where the labeling once stated that 
Zilretta is not intended for repeat administration, the labeling now states that the safety and efficacy of repeat 
administration have not been demonstrated. There is currently medical literature which supports the safety and 
efficacy of a second injection of extended-release triamcinolone acetonide. A second injection of the drug 
would reasonably be expected to result in a similar magnitude and duration of clinical benefit as the first 
injection, and would be expected to be well-tolerated. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pre-
approve Zilretta.  
 
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 physician's services provided on February 4, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.
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 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 physician's services provided on February 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit (99202) provided on 
February 18, 2020. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 
copayment for each specialist visit for consultation, diagnosis, and treatment.  
 
You have been asked to pay a $30 copayment for the specialist office visit. 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 office visit (99202) provided on February 18, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says that this is not covered. 
 
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 Prolia for the enrollee.  
 
Benefits for this drug 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy (PT) services. 
 
You asked the Plan to pre-approve the PT services. The Plan denied your request. The Plan says PT is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 PT services. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that the records do not show that skilled therapy is needed to 
effectively provide treatment, care, and/or services in order to improve the enrollee's level of function, or to 
establish/perform a maintenance program to maintain the enrollee's level of function and/or prevent 
deterioration. The enrollee had prior therapy and the documentation does not reveal recent functional level 
deficits that require ongoing skilled professional therapy. 
 
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 PT services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve physical therapy (PT) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing rendered to you on December 16, 2019. 
 
You asked the Plan to pay for these services. You say that you had a drug test for work. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that services that do not contribute meaningfully to the 
treatment of an illness or injury or the functioning of a malformed body member are not covered. 
 
We looked at the file and Medicare rules. The file shows that you received drug testing for the purposes of 
employment and not for the treatment of an illness, injury, or functioning of a malformed body member. 
Therefore, we decided that the Plan does not have to pay for the drug testing rendered to you on December 16, 
2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Procrit (J0885).
You asked the Plan to pre-approve the Procrit. You say that Procrit is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the information submitted does not meet the Plan's medical necessity guidelines for coverage.
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 Procrit. Our reviewer says that Procrit does not meet coverage criteria. Our physician reviewer found there is no evidence that the enrollee is allergic to or intolerant of Retacrit. There is no evidence that the enrollee has tried and not responded to Retacrit. Our reviewer found that there is no documentation as to why Retacrit would not be expected to be safe and effective for the enrollee. Our physician reviewer also found that the requested Procrit is not shown to be currently medically necessary and reasonable.
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 Procrit have not been met. Therefore, we decided that the Plan does not have to pre-approve Procrit (J0885).