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

 
We decided that the Plan does not have to waive the co payment for the MRI provided. 
 
You asked the Plan to waive the co payment for the MRI. You say that you feel you should not be responsible 
for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your 
request. The Plan says you received an MRI on the date of service at issue in this appeal. The Plan says that the 
correct co payment has applied per your contract with the Plan. 
 
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 $75 
copayment for Outpatient diagnostic tests.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received an MRI. 
You have been asked to pay a $75 copayment for the MRI. The MRI falls within the Outpatient 
diagnostic tests benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for the MRI provided.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copay for the specialist office visit provided on August 11, 
2020. 
 
You asked the Plan to waive the copay for the office visit. You say that your appointment with a retiring doctor 
should have never occurred. The Plan denied your request. The Plan says the claim was processed 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 $40 
copay for each specialist visit.  
 
You have been asked to pay a $40 copay for the specialist visit. The service falls within the physician services 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copay for the specialist office visit provided on 
August 11, 2020.  
 
Your complaint about seeing a retiring physician is not a valid appeal for medical coverage. This part of your 
complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision 
about these types of complaints.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ultrasound services provided on July 
20, 2020. 
 
You asked the Plan to waive the copayment for the ultrasound services. You say that you feel you should not 
be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan 
denied your request. The Plan says you received an ultrasound provided in an outpatient hospital setting on the 
date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract 
with the Plan. 
 
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 $250 
copayment for Medicare-covered Ultrasounds provided at an outpatient hospital setting.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received an ultrasound at 
an outpatient hospital setting on July 20, 2020. You have been asked to pay a $109.69 copayment for the 
ultrasound services, which is less than the $250 contracted copayment amount. The ultrasound services fall 
within the Outpatient diagnostic tests benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
the ultrasound services provided on July 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of residual tooth roots for tooth #2 coded as 
D7250. 
 
You asked the Plan to pre-approve the residual root removal. You say that you need the requested service. The 
Plan denied your request. The Plan says coverage cannot be approved for removal of residual roots as this does 
not appear to be the service that is necessary in this case. 
 
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. The Plan covers the residual 
root removal when the services are medically necessary and reasonable.  
 
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 residual root removal. Our reviewer 
says that the documentation does not support the need for the requested service. Our physician reviewer found 
the requested code does not appear appropriate for the requested service. The presentation of tooth #2 is a 
heavily decayed tooth with prior restoration that would likely break off on attempted removal. The provided x-
ray does not show simply residual roots, but some coronal structure remaining. As such the proper code would 
be for a surgical extraction of the tooth, but not under the provided code. The treatment under the code is not 
reasonable and necessary. A proper surgical code would be required for a finding of necessity. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the residual root removal have not been met. Therefore, we decided that the 
Plan does not have to pre-approve removal of residual tooth roots for tooth #2 coded as D7250.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital services rendered 
from June 23, 2020 to June 24, 2020. 
 
You asked the Plan to waive the copayment for these services. You say that you are being billed for six days 
instead of five. The Plan denied your request. The Plan says the copayment 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 $380 
copayment per day for days 1-5 for covered hospital care.  
 
Review of the file shows that you received one day of inpatient hospital care from June 23, 2020 to June 24, 
2020. The file shows that you were discharged from one hospital and admitted to a different facility. You have 
been asked to pay a $380 copayment for these services. These services fall within the covered 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 the inpatient hospital services 
rendered from June 23, 2020 to June 24, 2020.
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 
on June 26, 2020. 
 
You asked the Plan to pay for the self-administered drugs. You say that you could not administer the drugs. 
You also say that they were given before your surgery. The Plan denied your request. The Plan says the drugs 
that 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 on June 26, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Bevacizumab-awwb (Q5107). 
 
You asked the Plan to pre-approve Bevacizumab-awwb. The Plan denied your request. The Plan says there was 
no clinical information submitted. The Plan also says that the medical necessity for coverage of Bevacizumab-
awwb has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met.  
 
We looked at the file and Medicare rules. The Plan requested medical records from the provider, however, they 
were not submitted. Hence, it has not been shown that coverage criteria are met. Based on this information, we 
decided that Medicare rules for coverage of Bevacizumab-awwb have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Bevacizumab-awwb (Q5107).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve an inpatient rehab facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF services. The Plan denied your request. The Plan says that it is not 
expected that the enrollee can complete an intensive therapy program. 
 
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. 
 
MAXIMUS made several attempts to obtain the medical records used in their decision to deny services. 
However, none were provided. The Plan has not made reasonable and diligent efforts to gather and forward to 
us information regarding their decision to deny your request. Therefore, we decided that the Plan has to pre-
approve an inpatient rehab facility (IRF) admission and services.   
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services. 
 
You asked the Plan to pay for the ambulance services. You say that you believe that covering this service is 
imperative to allow for continued services to patients. The Plan denied your request. The Plan says these 
services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on May 27, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you required supervision for bathing and dressing. You required minimal assistance 
to walk 80 feet times two using a rolling walker. The documentation does not support that you require an acute 
hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not 
support that you require an intensive rehabilitation therapy program provided in an IRF. Your care needs can 
be met at lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675). 
 
You asked the Plan to pay for a pneumatic compression device. You say that the claim should be paid. The 
Plan denied your request. The Plan says the pneumatic compression device is not covered by Medicare to 
prevent deep vein thrombosis during and/or following surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. PCDs billed by E0675 are 
not covered. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided 
that the Plan does not have to pay for a pneumatic compression device (E0675).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copay for the diagnostic testing provided on July 24, 2019. 
 
You asked the Plan to waive the copay for the testing services. You say that you never had to pay a copay 
before. The Plan denied your request. The Plan says the claim processed correctly per the benefit plan. 
 
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 $10 
copay for diagnostic procedures and tests.  
 
You have been asked to pay a $10 copay for the testing services. The services fall within the outpatient 
diagnostic tests 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 diagnostic testing provided 
on July 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intermittent limb compression device. 
 
You asked the Plan to pay for intermittent limb compression device. You say that the claim should be paid. The 
Plan denied your request. The Plan says pneumatic compression devices are not covered by Medicare for 
edema or venous insufficiency without ulcers. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
The file does not show that the enrollee has lymphedema and/or chronic venous insufficiency with venous 
stasis ulcers. Therefore, we decided that the Plan does not have to pay for intermittent limb compression 
device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that a bathing transfer chair is medically necessary. 
The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the orthoses provided on July 2, 2020. 
 
You asked the Plan to pay for the orthoses. The Plan denied your request. The Plan says the enrollee denies 
speaking with the physician. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. The record shows 
that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we 
decided that the Plan does not have to pay for the orthoses provided on July 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stair lift. 
 
You asked the Plan to pre-approve a stair lift. You say that you are eligible for this device and it is medically 
necessary. The Plan denied your request. The Plan says the denial of authorization for this device is correct, 
because it is not covered by Medicare. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve a stair lift.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services. 
 
You asked the Plan to pay for the ambulance services. You say that due to COVID-19 there were concerns 
about taking the enrollee to the hospital, and had the ambulance staff recommended that the enrollee go to the 
hospital you would have followed the instructions. The Plan denied your request. The Plan says these services 
are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on July 11, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services. 
 
You asked the Plan to pay for the ambulance services. You say that you refused transportation because you 
were frightful of dealing with exposure to COVID-19. The Plan denied your request. The Plan says these 
services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the outpatient surgery provided on June 1, 
2020. 
 
You asked the Plan to waive the coinsurance for the outpatient surgery. You say that you feel you should not be 
responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied 
your request. The Plan says you received outpatient surgery on the date of service at issue in this appeal. The 
Plan says that the correct coinsurance has applied per your contract with the Plan. 
 
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 each covered surgery or observation room service in an outpatient hospital.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows you received outpatient surgery on 
June 1, 2020. You have been asked to pay a 20% coinsurance for the outpatient surgery, totaling $2288.60. The 
outpatient surgery falls within the Outpatient surgery 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 outpatient surgery provided on June 1, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular nerve block to the left knee. 
 
You asked the Plan to pre-approve genicular nerve block. 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 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 genicular nerve block. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has chronic low back pain left knee pain secondary to osteoarthritis. The 
knee pain has been treated with medical therapy including opiates, bracing, and physical therapy. Genicular 
nerve blocks and genicular nerve ablation are considered investigational and not medically necessary for the 
treatment of chronic knee pain, including, but not limited to any of the following: degenerative joint disease; 
osteoarthritis of the knee; as a treatment prior to knee replacement; as a treatment following knee replacement; 
or as a treatment for individuals who are not candidates for knee replacement surgery. Therefore, the enrollee 
does 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 genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve genicular nerve block to the left knee.