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

We decided that the Plan does not have to waive the copayment for a Positron Emission Tomography (PET) scan.

You asked the Plan to waive the copayment for PET scan. You say that you were never told you would have a copayment for this test, or you would not have had it. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.

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 $250 copayment for PET scan in a non-preferred hospital radiology facility.

You have been asked to pay $250 copayment for PET scan. PET scan falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 Positron Emission Tomography (PET) scan.

Your complaint regarding not being told about the cost-sharing for this service is considered to be a grievance. Maximus Federal Services does not have the jurisdiction to address grievances. Please contact the Plan for more information about your grievance.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory testing provided on August 27, 
2020. 
 
You asked the Plan to waive the copayment for lab tests. You say that you have never gotten a copay for 
bloodwork before. The Plan denied your request. The Plan says the copayment amount you are being charged 
is correct. 
 
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 $20 
copayment for lab tests.  
 
You have been asked to pay $20 copayment for lab tests. Lab tests fall within the Outpatient Diagnostic Tests 
and Therapeutic Services and Supplies 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 laboratory testing provided on August 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on November 9, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for clinic visit. You say that you are appealing based on medical necessity. The Plan 
denied your request. The Plan says the denial of payment for this service is correct, because this provider is 
out-of-network with the Plan and authorization was not obtained. 
 
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 medical services provided on November 9, 
2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc injections (J7325). 
 
You asked the Plan to pre-approve Synvisc. You say that Synvisc 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 Synvisc. Our reviewer says that 
Synvisc is not medically necessary. Our physician reviewer found the record shows no trial of the plan 
preferred drugs, or any reason why the plan preferred drugs 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 Synvisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Synvisc injections (J7325).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the powered pressure-reducing air mattress (E0277).
 
You asked the Plan to pre-approve the powered pressure-reducing air mattress. You say that this service is 
medically necessary. The Plan denied your request. The Plan says the Medicare criteria for coverage is not met.
 
The Plan follows Medicare rules. Medicare rules say that a group 2 support surface is only covered if certain 
criteria are met.
 
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 powered pressure-reducing air 
mattress. Our reviewer says that the requested mattress is not medically necessary. Our physician reviewer 
found there is no clear documentation that the enrollee has large or multiple stage III or IV pressure ulcer(s) on 
the trunk or pelvis.
 
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 powered pressure-reducing air mattress have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the powered pressure-reducing air mattress (E0277).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Supartz.

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 the step therapy requirement is not met.

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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has osteoarthritis and has not tried and failed the Plan's required drugs, Orthovisc and Monovisc. The records do not support that the required drugs would be contraindicated or less effective; therefore, the requested Supartz is not reasonable or medically necessary at this time.

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 not been met. Therefore, we decided that the Plan does not have to pre-approve Supartz.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve colonoscopy. You say that you are appealing this denial. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this provider is out-of-network with the Plan and you can be treated by an in-network provider.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
May 29, 2020, to June 30, 2020. 
 
You asked the Plan to waive the copayment for inpatient stay. You say that this hospital stay was due to 
COVID-19 and you cannot afford this bill. The Plan denied your request. The Plan says the copayment amount 
you are being charged is correct. 
 
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 $300 
copayment per day for days 1 to 5 and $0 copayment per day for days 6 to 90 for inpatient stay. This inpatient 
stay lasted 32 days, resulting in a copayment obligation of $1,500. 
 
You have been asked to pay $300 copayment per day for days 1 to 5 and $0 copayment per day for days 6 to 90 
for inpatient stay. Inpatient stay falls within the Inpatient Hospital 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 an inpatient hospital stay provided from May 29, 2020, to June 30, 
2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for duplex scans provided on May 26, 2020. 
 
You asked the Plan to waive the copayments for duplex scans. You say that you were told that you would only 
owe a $30 copayment. 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 $160 
copayment for each radiological diagnostic service.  
 
You received two duplex scans on May 26, 2020. Duplex scans are considered radiological diagnostic services. 
Therefore, you are responsible to pay the total allowed amount of $249.73, which is less than the total 
copayment amount.  
 
You have been asked to pay $249.73 for duplex scans. Duplex scans fall within the outpatient diagnostic tests 
and therapeutic services and supplies 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 copayments for 
duplex scans provided on May 26, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for a Medicare Part B prescription drug and eye injection procedure.

You asked the Plan to waive the cost-sharing for Part B drug and eye injection. You say that you paid a copayment on the day of the procedure and should not owe this amount. The Plan denied your request. The Plan says the cost-sharing amounts you are being charged are correct.

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 20% coinsurance for Part B drug and $20 copayment for eye injection. The allowed amount of the Part B drug is $125, resulting in a coinsurance amount of $25. Your total cost-sharing obligation is therefore $45.

You have been asked to pay 20% coinsurance for Part B drug and $20 copayment for eye injection. Part B drug and eye injection fall within the "Medicare Part B Prescription Drugs" and "Vision Care" benefit categories. 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 cost-sharing for a Medicare Part B prescription drug and eye injection procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to further reimburse you for the home monitoring test supplies (G0249) 
provided May 27, 2020. 
 
You asked the Plan to further reimburse you for home monitoring test supplies. You say that you believe you 
should receive further reimbursement from the Plan. The Plan denied your request. The Plan says this claim 
processed correctly, and no further reimbursement is due. 
 
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 20% 
coinsurance for durable medical equipment.  
 
You have been reimbursed a total amount of $49.98 based on the Medicare allowed amount for home 
monitoring test supplies minus the coinsurance ($54.98 Allowed amount x 20% coinsurance). Although you 
received a bill greater than the Medicare allowed amount, the Plan is only liable for processing their cost share 
with the Medicare allowed amount. Home monitoring test supplies falls within the durable medical equipment 
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 further reimburse you for the home monitoring test 
supplies (G0249) provided May 27, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a speech therapy evaluation.

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 the services are 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 these 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 the requested therapy is not generally accepted as specific and effective therapy for your condition. You have had extensive therapy for this condition and the documentation does not indicate that your functional level requires the unique skills of a professional speech therapist to safely and effectively provide treatment, or that the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. The services are not part of a maintenance program and are not needed to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration.

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 not been met. Therefore, we decided that the Plan does not have to pre-approve a speech therapy evaluation.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for wound repair provided on October 19, 
2020. 
 
You asked the Plan to waive the copayment for wound repair. You say that you feel that you are being 
balanced billed. 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 $175 
copayment for outpatient surgery, including services provided at ambulatory surgical centers.  
 
You received wound repair on October 19, 2020, at an ambulatory surgical center. Wound repair is considered 
a surgical procedure. Therefore, you are responsible to pay the $175 copayment.  
 
You have been asked to pay a $175 copayment for wound repair. Wound repair falls within the outpatient 
surgery, including services provided at outpatient facilities and ambulatory surgical centers 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 wound repair provided on October 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve removable orthotic shoe inserts for longitudinal/metatarsal support.

You asked the Plan to pre-approve the orthotic inserts. You say that you have severe foot pain for which these inserts are medically necessary. You state that you also have recently been diagnosed with diabetes, so you meet criteria for the items for multiple reasons. The Plan denied your request. The Plan says you do not have a condition for which this item may be covered.

The Plan must follow Medicare rules. Medicare rules say that shoe inserts may be covered for those who use a leg brace of which a shoe is an integral component. In addition, it may be covered for enrollees with diabetes who have signs of diabetic foot disease, when the certifying physician has documented a comprehensive plan of care for diabetes and certifies that diabetic shoes are needed.

In this case, the inserts are not for shoes that are an integral part of a leg brace. Also, there is not clear documentation of the presence of diabetic foot disease. Although there are some signs of poor circulation, the record does not show that there is a comprehensive diabetes plan of care at this time, and the physician has not indicated that diabetic shoes are needed. The prescription shows that the shoes are needed due to tendinitis. While this may be appropriately treated with the requested inserts, this is not a condition for which diabetic shoes may be covered. Therefore, we decided that the Plan does not have to pre-approve removable orthotic shoe inserts for longitudinal/metatarsal support.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency treatment of dental pain provided on October 
7, 2020. 
 
You asked the Plan to pay for the emergency treatment of dental pain. You say that although you know this 
service is not covered, you believe this service should be covered because you were under the annual maximum 
amount of coverage for the year. The Plan denied your request. The Plan says this service is not covered. 
 
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. Therefore, we decided that the Plan does not have to pay for the 
emergency treatment of dental pain provided on October 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the four gingival irrigations (D4921 x4) provided on October 
16, 2020. 
 
You asked the Plan to pay for the four gingival irrigations. The Plan denied your request. The Plan says this 
service is not covered by the Plan. 
 
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. Therefore, we decided that the Plan does not have to pay for the four 
gingival irrigations (D4921 x4) provided on October 16, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider for a computed 
tomography (CT) scan. 
 
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 the services are available from network providers. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a referral to an out-of-network provider for a computed tomography (CT) scan.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Brovana. 
 
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 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 not medically necessary. Our physician reviewer found the records show that the enrollee is 
using another long-acting beta agonist (LABA)- Breo Ellipta (fluticasone/vilanterol) at standard doses. This 
duplicate therapy with two LABAs is not supported by compendia, authoritative medical literature, and the 
Medicare rules. There is no documentation that he has discontinued either drug. The Brovana is 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Brovana.