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

We decided that the Plan does not have to pre-approve Hyalgan. 
 
You asked the Plan to pre-approve Hyalgan. You say that the requested Hyalgan is medically necessary. The 
Plan denied your request. The Plan says the enrollee must try and fail Monovisc first. 
 
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 Hyalgan. Our reviewer says that the 
Plan's step therapy criteria have not been met. Our physician reviewer found the review indicates that the 
enrollee is with a history of osteoarthritis of the left knee. His provider has requested viscosupplementation 
with Hyalgan. 
 
The Plan requires a trial of Monovisc first before they will approve the requested drug. In this case, the enrollee 
has not tried and failed the required drug. Step therapy, as outlined by the plan, requires this to be trialed first. 
The documentation does not outline contraindications or reasons these medications were not considered. 
Without the support of the documentation, Hyalgan is not approved, as step criteria have not been 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 Hyalgan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Hyalgan.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to waive the copayment for the ECG provided on July 31, 2020. 
 
You asked the Plan to waive the copayment for the ECG. You say that you never received the ECG on July 31, 
2020. The Plan denied your request. The Plan says that the claim was reprocessed and you have been charged a 
lesser 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 enrollees must pay a $95 copayment for in-network diagnostic procedures and 
tests performed by a provider other than your primary care physician.  
 
The Plan says you must pay the lesser copayment amount of $25 for the ECG. Based on the Plan contract, 
however, you cannot be asked to pay more than a $0 copayment for the ECG. The medical record shows that 
the ECG was cancelled. Therefore, we decided that the Plan has to waive the copayment for the ECG provided 
on July 31, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the allergy injections provided from 
September 2, 2020, to September 23, 2020. 
 
You asked the Plan to waive the coinsurance for the allergy injections. You say that you would like to be 
reimbursed the coinsurance amount because the allergy shots are medically necessary. The Plan denied your 
request. The Plan says 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for all other drugs covered under Medicare Part B.  
 
You have been asked to pay $2.34 which is 20% of the allowed amount for the Part B drugs on each date of 
service. The allowed amount is $11.68. ($11.68 x 20% = $2.34) ($2.34 x 3 dates of service = $7.02). The 
allergy injections 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 allergy injections provided from September 2, 2020, to 
September 23, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus Gene Panel testing provided on July 2, 2020. 
 
You asked the Plan to pay for the testing services. You say that the test was performed for clinical management 
of the enrollee's advanced cancer. The Plan denied your request. The Plan says the test is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that next generation sequencing is only covered under 
certain medical indications.   
 
We looked at the file and Medicare rules. The records provided do not indicate that the enrollee has decided to 
seek further cancer treatment. The records do not show that the results will determine a specific treatment 
strategy. Based on this information, we decided that Medicare rules for coverage of the testing services have 
not been met. Therefore, we decided that the Plan does not have to pay for the Tempus Gene Panel testing 
provided on July 2, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gilotrif tab 30mg 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is denied as a benefit exclusion. 
 
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 Gilotrif tab 30mg
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided December 27, 2019 
to December 30, 2019. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the records provided should support 
the necessity of the service in dispute. The Plan denied your request. The Plan says based on the limited clinical 
data submitted this request was not medically necessary. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found there was very limited medical records to review. An EGD with no documentation of 
serious consequence. The documentation provided does not justify admission status. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided December 27, 2019 to December 30, 
2019.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synthroid for the enrollee. 
 
You asked the Plan to pre-approve Synthroid. You say that this is medically necessary for the enrollee. The 
Plan denied your request. The Plan says that this is not covered under Part B. 
 
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 Synthroid for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on July 30, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the subsequent nursing facility care. You say that you would like reconsideration 
because the services were medically necessary and no prior authorization was obtained because the services 
were not pre-arranged. The Plan denied your request. The Plan says the services were not urgent or emergent 
and prior 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 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 July 30, 2020 by 
an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting 
from September 1, 2020, to September 3, 2020. 
 
You asked the Plan to pay for the self-administered drugs. You say that the enrollee did not have any self-
administered drugs. You say that the enrollee did not receive all of her medications. You also say that the 
hospital called you only once while the enrollee was in the hospital. The Plan denied your request. The Plan 
says the drugs you received are considered self-administered. The Plan says self-administered drugs are 
covered under a Medicare Part D prescription drug plan. The Plan also says the drugs you received are not 
covered under Medicare Part B. 
 
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 pay for the self-administered drugs 
provided in an outpatient setting from September 1, 2020, to September 3, 2020.  
 
Benefits for the self-administered drugs 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gym membership purchased. 
 
You asked the Plan to pay for the gym membership. You say that you had switched over to another center due 
to the limitations your other fitness center had enforced due to COVID. You state that you are asking for 
coverage of the membership for an academic year rather than a calendar year. The Plan denied your request. 
The Plan says you exhausted your maximum benefit allowance. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case.  
 
Your EOC states, "you receive reimbursement for up to a combined total of $240 per year for approved 
services. The date of service for this benefit is the date you make payment. For example, if you pay on  for a gym membership that starts January 1. December 15 is the date of service. Review of the 
file shows that you had paid for the monthly reimbursement, 
at your old fitness center and a new membership at the new fitness center. Since you 
were reimbursed the $240 maximum, the Plan cannot reimburse an additional $240. Therefore, we decided that 
the Plan does not have to pay for the gym membership purchased.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on February 26,
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 Medicare billing criteria were not met. Maximus overturned the Plans denial for
insufficient information regarding the claim. The Plan requested a reopen and provided additional claim
information.
The Plan says that this claim denied because the provider was not eligible for payment of this service. The
Plan states that the NPI Registry website the billing provider is registered as a Nurse Practitioner Acute Care.
However, the provider did not bill with this taxonomy. The provider billed with the taxonomy of a Registered
Nurse. The Plan states the Rendering Provider Information shows that the provider has billed incorrectly with
an incorrect taxonomy. A Registered Nurse taxonomy is not eligible to receive Medicare reimbursement.
Therefore, this claim could not be paid as billed.
The Plan must follow Medicare rules. Medicare requires providers to submit a valid taxonomy code for claim
payment. In this case, we have confirmed the taxonomy code submitted is not a valid code for Medicare
purposes. Medicare billing criteria are not met. Therefore, we decided that the Plan does not have to pay for
physician services provided to the enrollee on February 26, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infection control supplies and IV tubing extension set 
rendered on June 2, 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 procedure codes S1015 and S8301 are not covered. 
 
The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid 
for Medicare purposes.  
 
We looked at the file and Medicare rules. Billed codes S1015 and S8301 have a status indicator of I and are not 
valid for Medicare purposes. Therefore, we decided that the Plan does not have to pay for the infection control 
supplies and IV tubing extension set rendered on June 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown (D2740) provided on June 4, 2020. 
 
You asked the Plan to pay for the crown (D2740). You say that you don't understand why the claim was 
denied. You say that according to your policy non-Medicare covered comprehensive dental services and non-
routine services are covered with 50% coinsurance. The Plan denied your request. The Plan says the service is 
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. Therefore, we decided that the Plan does not have to pay for the crown 
(D2740) provided on June 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for urology services provided January 27, 
2020 to July 21, 2020. 
 
You asked the Plan to waive the copayments for the urology services. You say that the copayments should be 
waived. The Plan denied your request. The Plan says the correct cost-sharing was 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). Your contract with the Plan clearly says that you must pay a $30 
copayment for specialist visits.  
 
You have been asked to pay a $30 copayment for each urology visit. The urology services fall within the 
specialist visits 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 urology services provided 
January 27, 2020 to July 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral exam (D0120), prophylaxis (D1110), and the 
complete series x-ray (D0210) provided on August 19, 2020. 
 
You asked the Plan to pay for the dental services. You say that your provider does not bill insurances. You say 
that you paid out of pocket for the services. You also say that your plan allows for $1,000 for preventative and 
comprehensive dental combined services. The Plan denied your request. The Plan says the provider in this case 
has opted out Medicare. The Plan says that payment cannot be made for services that you received from a 
provider who has opted out of Medicare. 
 
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. Therefore, we decided that the Plan does not have to pay for the oral 
exam (D0120), prophylaxis (D1110), and the complete series x-ray (D0210) provided on August 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for lead wires, (e.g., apnea monitor), per pair (CPT Code A4557) 
provided on September 19, 2020. 
 
You asked the Plan to pay for the DME. You say that the claim should be paid. The Plan denied your request. 
The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the DME have not been met. This is denied because a 
transcutaneous electrical nerve stimulation (TENS) unit has been purchased in the previous twelve (12) months 
for the TENS device, four or more leads, for multiple nerve stimulation (CPT Code E0730) billed by the same 
provider for date of service May 19. 2020, for date of service June 19, 2020, and for date of service July 19, 
2020. Per CMS LCD L33802, "Replacement of lead wires more often than every 12 months would rarely be 
reasonable and necessary. Since a TENS unit has been purchased in the previous 12 months, the lead wires 
have been denied. Records supporting the medical necessity of the additional lead wires were not submitted. 
Therefore, we decided that the Plan does not have to pay for lead wires, (e.g., apnea monitor), per pair (CPT 
Code A4557) provided on September 19, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on August 3, 2020, by an out-
of-network provider. 
 
You asked the Plan to pay for the medical services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services were not referred by a network provider or rendered in a participating 
facility. The Plan states these services are not urgent or emergent, nor were they approved in advance.  
 
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 3, 2020, 
by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve radiofrequency ablation (RFA). You say that the requested radiofrequency 
ablation (RFA) is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet 
criteria for the requested radiofrequency ablation (RFA). 
 
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 radiofrequency ablation (RFA). Our 
reviewer says that the enrollee does not meet criteria for the requested radiofrequency ablation (RFA). Our 
physician reviewer found the enrollee has axial low back pain and had one set of diagnostic MBBs. She 
achieved 80% pain relief. The request is for RFA of the MBBs.  
 
The LCD requires 2 separate sets of MBBs that produce 80% pain relief.  Here only one set of diagnostic 
blocks has been performed.  Therefore, the request is premature.  At this point, the request is considered to be 
not medically reasonable and 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 radiofrequency ablation (RFA) have not been met. Therefore, we decided that 
the Plan does not have to pre-approve radiofrequency ablation (RFA).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on February 25, 2020, by an 
out-of-network provider. 
 
You asked the Plan to pay for the medical services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the provider is out-of-network with the member's Plan, the services were not 
approved in advance and the services were not urgent or emergent. 
 
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 February 25, 
2020, by an out-of-network provider.