Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Victoza injections. 
 
You asked the Plan to pre-approve Victoza injections. You say that the medication is necessary. The Plan 
denied your request. The Plan says the enrollee has a medical only policy which does not include Part D 
prescription coverage, therefore the criteria for self-administered drug coverage has not been met. 
 
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 Victoza injections.  
 
Benefits for Victoza injections 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0120). 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that the requested additional 
transportation is necessary. The Plan denied your request. The Plan says the requested additional transportation 
trips exceed the benefit limit. Therefore, coverage criteria has not been met. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers a maximum of 30 one-way transportation trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips (A0120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We are dismissing your case. Your complaint is not a valid appeal for medical coverage. The record does not show that the Plan denied coverage of Sublocade. Instead, you have asked the Plan to waive any cost-sharing that may be applied for these services when they are provided. MAXIMUS Federal Services cannot review requests related to cost-sharing for services that have not yet taken place. Your complaint is a grievance that must be answered by the Plan directly.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen therapy. 
 
You asked the Plan to pre-approve hyperbaric oxygen therapy. 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 medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that hyperbaric oxygen therapy is only 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 hyperbaric oxygen therapy. Our 
reviewer says that the documentation does not support that the requested hyperbaric oxygen therapy is 
medically reasonable or necessary. Our physician reviewer found you have been diagnosed with asymmetric 
sensorineural hearing loss, chronic otitis media, and rhinitis. The documentation does not support that you have 
a a diagnosis, condition or symptoms which might meet Medicare criteria for hyperbaric oxygen therapy. 
Evidence suggests a possible role for hyperbaric oxygen therapy in enrollees with immediate and sudden 
hearing loss, but not for chronic cases, such as this one. Therefore, you do not meet criteria for the requested 
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 hyperbaric oxygen therapy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve hyperbaric oxygen therapy.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CT scan of the heart with quantitative evaluation of 
coronary calcium. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says quantitative calcium scoring is not a covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that quantitative calcium scoring is not a covered 
service.  
 
This scan cannot be covered as it includes quantitative calcium scoring. Based on this information, we decided 
that Medicare rules for coverage of the scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a CT scan of the heart with quantitative evaluation of coronary calcium.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Brovanna. 
 
You asked the Plan to pre-approve Brovanna. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says the criteria for coverage have not been 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 Brovanna. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the Plan requires a trial of the drug 
Perforomist before they will approve the requested drug. The medical records do not show that the enrollee has 
tried and failed the required drug. The medical records provided no indication that the required drug would 
likely be less effective and/or likely to have adverse effects 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 Brovanna have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Brovanna.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medical services to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve the OON services. You say that it is easier to get to the requested provider. 
The Plan denied your request. The Plan says the requested 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 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 services at issue in this appeal. We were able to confirm that the Plan has 
contract providers located within reasonable distance and travel time from your home. 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 medical services to be provided by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an outpatient surgery provided by a 
participating provider on May 6, 2020. 
 
You asked the Plan to waive the coinsurance for a laminectomy. You say that you did not have a surgery. The 
Plan denied your request. The Plan says the correct coinsurance has been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay a 20% coinsurance for outpatient surgery.  
 
The enrollee has been asked to pay a 20% coinsurance of the allowed amount for a laminectomy. The total 
allowed amount is $6,583.12. The total amount you are being asked to pay is $1,316.62 ($6,583.12 x 20% = 
$1,316.62). A laminectomy falls within the outpatient surgery benefit category. This means that the enrollee 
has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual 
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not 
have to waive the coinsurance for an outpatient surgery provided by a participating provider on May 6, 2020.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for paramedic intercept (A0432) provided on December 20, 2019. 
 
You asked the Plan to pay for the paramedic intercept. You say that you would like reconsideration because 
this service was reported correctly. The Plan denied your request. The Plan says that CPT code A0432 was not 
reported with a mileage code or appropriate modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules also say that for ambulance service claims, institutional-based providers and suppliers must report an 
origin and destination modifier for each ambulance trip provided in HCPCS/Rates. In addition, institutional-
based providers must report a QM or QN modifier. 
 
We find that CPT code A0432 is supported in the record. Specifically, the supplier in this case has reported an 
origin and destination modifier. The supplier did not provide ambulance transportation and is not an 
institutional based provider. Reporting of mileage and/or a QM/QN modifier would therefore be inappropriate. 
Based on this information, we decided that Medicare rules for coverage of the paramedic intercept have been 
met. Therefore, we decided that the Plan has to pay for paramedic intercept (A0432) provided on December 20, 
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the portable oxygen concentrator provided on May 6, 2020.

You asked the Plan to pay for the provided device. You say that the portable oxygen compressor is too big to take out and carry around. The Plan denied your request. The Plan says coverage of the device is only considered when it is rented.

The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary.

The file shows that you already had a portable oxygen concentrator at the time the device at issue was purchased. Your current device serves the same purpose as the light-weight device that was purchased. Based on this information, we decided that the Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the portable oxygen concentrator provided on May 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on August 28, 2019 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were rendered by an out-of-network provider without 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 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 medical services provided on August 28, 2019 
by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a respiratory assist device provided on 
March 18, 2020. 
 
You asked the Plan to waive the coinsurance for respiratory assist device. You say that you paid a lower 
amount in 2019 and feel like this increase is unreasonable. The Plan denied your request. The Plan says the 
coinsurance 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% 
coinsurance for respiratory assist device. The allowed amount of the claim is $165.22, resulting in a 
coinsurance obligation of $33.04. 
 
You have been asked to pay 20% coinsurance for respiratory assist device. Respiratory assist device falls 
within the Durable Medical Equipment (DME) and Related 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 coinsurance for a respiratory assist device provided on March 18, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on January 22, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says screening tests are not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test 
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory 
services rendered on January 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copay for the eye exam provided on August 8, 2019. 
 
You asked the Plan to waive the copay for the eye exam. You say that you can have an eye exam with a $0 
copay. The Plan denied your request. The Plan says the copay was applied correctly. 
 
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 $25 
copay per visit for Medicare-covered exams to diagnose and treat disease of the eye.  
 
The file shows you received an eye exam in which you were treated for your cataracts diagnosis. This means 
that the exam was not considered a routine eye exam. You have been asked to pay a $25 copay for the eye 
exam. The exam falls 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 copay for 
the eye exam provided on August 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided from February 28, 
2020 to March 13, 2020. 
 
You asked the Plan to pay for the domiciliary or rest home visit. 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 
service 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 a domiciliary or rest home visit provided from February 28, 2020 
to March 13, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the pain pump services rendered from 
January 14, 2020 to May 21, 2020. 
 
You asked the Plan to waive the coinsurance for these services. You say that you disagree with the charges. 
The Plan denied your request. The Plan says the coinsurance was applied correctly. 
 
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 Medicare Part B prescription drugs.  
 
Review of the file shows that you received pain pump services from January 14, 2020 to May 21, 2020. You 
have been asked to pay a 20% coinsurance for these services. These services fall within the Medicare Part B 
prescription drugs 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 coinsurance for the pain pump 
services rendered from January 14, 2020 to May 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided on March 11, 2020. 
 
You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says that the 
Plan requires utilization of network providers when possible and available, and requires authorization for 
certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency 
situation, has been documented. 
 
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 
psychotherapy services. 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 psychotherapy services provided on March 11, 
2020.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the coinsurance for a Remicade intravenous infusion (J1745) performed 
on April 15, 2019. 
 
You asked the Plan to waive the coinsurance for a Remicade intravenous infusion. You say that you had 
satisfied your annual out-of-pocket maximum and this coinsurance should not be your responsibility. The Plan 
denied your request. The Plan says that the correct coinsurance was applied. 
 
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 enrollees must pay 20% coinsurance for Medicare Part B prescription drugs.  
 
In this case, the Plan initially assessed a coinsurance of $356.71 but has since revised its assessment. The Plan 
now says you must pay $305.17 or 20% coinsurance for a Remicade intravenous infusion. However, the case 
record does not clarify whether you have paid the prior charge of $356.71. The case record also does not 
provide documentation to support the Plan's argument that you had not reached your annual out-of-pocket 
maximum prior to receiving a Remicade intravenous infusion on April 15, 2019. We attempted to contact the 
Plan to correct the case record but were unable to obtain a response within the timeframe required for review of 
this case. Therefore, we decided that the Plan has to waive the coinsurance for a Remicade intravenous infusion 
(J1745) performed on April 15, 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 waive the cost sharing for the specialist services and injection 
rendered on April 6, 2020 to April 20, 2020. 
 
You asked the Plan to waive the cost sharing for these services. You say that you disagree with the charges. 
The Plan denied your request. The Plan says the cost sharing was applied correctly. 
 
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 $45 
copayment for each Medicare-covered specialist visit and a 20% coinsurance for Part B drugs. 
 
Review of the file shows that you received specialist services on April 6, 2020; April 13, 2020; and April 20, 
2020. You have been asked to pay a $45 copayment per date of service for these services, for a total of $135. 
These services fall within the Medicare-covered specialist visit benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan.  
 
The file shows that you received a Part B drug injection on April 6, 2020; April 13, 2020; and April 20, 2020. 
You have been asked to pay a 20% coinsurance for these services, for a total of $105.63 ($35.21 per date of 
service). These services fall within the Part B drugs 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 cost sharing for the specialist services and injection rendered 
on April 6, 2020 to April 20, 2020.