Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete series of intraoral x-rays and oral hygiene 
instructions provided on August 31, 2020. 
 
You asked the Plan to pay for the complete series of intraoral x-rays and oral hygiene instructions. You say that 
you looked for an in-network provider, and are now being billed for the services. The Plan denied your request. 
The Plan says these services are 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 
complete series of intraoral x-rays and oral hygiene instructions provided on August 31, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an exception to the 50 mile limit for routine 
transportation. 
 
You asked the Plan to pre-approve exceptions to supplemental benefits. You say that you require this 
transportation to get to your doctor visit. The Plan denied your request. The Plan says that this request exceeds 
your benefit limit. 
 
Medicare does not cover routine transportation. While plans may offer supplemental transportation benefits 
they are not required to do so. Medicare does not provide exceptions to supplemental benefits. Therefore, we 
decided that the Plan does not have to pre-approve an exception to the 50 mile limit for routine transportation.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT scan of the chest, abdomen, and pelvis for the 
enrollee. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says this request does not adhere to surveillance guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically 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 the scan. Our reviewer says that the 
requested scan is not medically reasonable or necessary. Our physician reviewer found no radiology reports 
from prior CT scans are included in the submitted records. Thus, the medical necessity of the requested scans 
cannot be assessed. If indeed there was a solitary pulmonary nodule on 8/26/20 as described in the records 
Fleischner Society recommendations do not advocate a 6 month follow-up for nodules less than 4 mm in 
diameter. Secondly, there is no clinical data to necessitate a CT of the pelvis aside from the prior history of 
prostate cancer; stage and therapy etc. are not specified in the records. Finally, without a report of the prior CT 
of the abdomen and the nature of the "hypodensities" cannot be assessed to determine medical necessity. 
 
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 scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve CT scan of the chest, abdomen, and pelvis for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing (81479). 
 
You asked the Plan to pre-approve genetic testing. You say that this should be covered. The Plan denied your 
request. The Plan says documentation has not been received to show this is medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say 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 the file and Medicare rules. Medical records or other documentation showing the requested service 
is medically necessary have not been submitted. Based on this information, we decided that Medicare rules for 
coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pre-
approve genetic testing (81479).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for shoulder elbow wrist hand orthosis (L3960) provided on 
August 6, 2020. 
 
You asked the Plan to pay for the shoulder elbow wrist hand orthosis. You say that you would like 
reconsideration because this equipment is medically necessary. The Plan denied your request. The Plan says the 
documentation does not include a valid proof of delivery or evidence that the provider discussed the need for 
the billed supply. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the shoulder elbow wrist hand orthosis. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the documentation is unclear why the member would require positioning in 
abduction with an airplane design orthosis; therefore, the documentation does not support that this orthosis is 
being furnished in a setting appropriate to the member's medical needs and condition. 
 
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 shoulder elbow wrist hand orthosis have not been met. Therefore, we 
decided that the Plan does not have to pay for shoulder elbow wrist hand orthosis (L3960) provided on August 
6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an upper partial denture (D5211). 
 
You asked the Plan to pre-approve the dental item. You say that you misplaced your partial denture. You also 
say that you need a new one. You say that you cannot chew your food without it. The Plan denied your request. 
The Plan says 1 upper partial denture is covered every 60 months. The Plan also says that the frequency limit 
has been reached. 
 
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 frequency limit of 1 upper partial 
denture per 60 months has been reached. The record shows that the Plan paid for an upper partial denture that 
you received on December 19, 2019, less than 60 months ago. Therefore, we decided that the Plan does not 
have to pre-approve an upper partial denture (D5211).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cardiovascular risk assessment panel provided to the 
enrollee on June 30, 2020. 
 
You asked the Plan to pay for the panel. You say that this was medically necessary. The Plan denied your 
request. The Plan says Medicare denies coverage for all cardiovascular risk assessment panels, except the basic 
lipid panel, for symptomatic patients with suspected or documented cardiovascular disease. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the panel. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there was no specific clinical rationale for the obtained lab study. The review has determined that the 
enrollee did not meet the criteria for this testing. 
 
 
 
 
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 panel have not been met. Therefore, we decided that the Plan does not have 
to pay for a cardiovascular risk assessment panel provided to the enrollee on June 30, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT scan of the abdomen and pelvis. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not describe the results of an ultrasound of the abdomen. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically 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 the scan. Our reviewer says that the 
requested scan is not medically reasonable or necessary. Our physician reviewer found you have epigastric 
pain, and no prior abdominal surgery. You have fatigue with a normal physical exam. There are no abnormal 
labs. Ultrasound has not been performed, and would be the most reasonable first step to evaluate the 
gallbladder, liver, pancreas, and pelvis. If such studies provided to be limited or indeterminate, CT scan may 
then be considered. 
 
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 scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve CT scan of the abdomen and pelvis.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve the sleep study. 
 
You asked the Plan to pre-approve the sleep study.. You say that you would like reconsideration because the 
member is currently on CPAP and has a residual Apnea Hypopnea Index (AHI) with significant complaints of 
difficulty exhaling against the constant pressure of the CPAP. The Plan denied your request. The Plan says that 
the records show that the member cannot tolerate a CPAP mask. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 the sleep study. Our reviewer says that 
the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found home pressure titration has been tried and failed. The issue is not intolerance of CPAP, but 
inadequate response to CPAP, with residual increased AHI, even after attempts to titrate pressures at home 
using auto-PAP. 
 
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 sleep study. have been met. Therefore, we decided that the Plan has to pre-
approve the sleep study.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardiovascular risk assessment testing provided to the 
enrollee on July 22, 2020. 
 
You asked the Plan to pay for this testing. You say that this claim should be paid. The Plan denied your 
request. The Plan says this type of testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case, the services billed are not covered by 
Medicare.  Therefore, we decided that the Plan does not have to pay for cardiovascular risk assessment testing 
provided to the enrollee on July 22, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided from August 13, 2020, to 
September 11, 2020. 
 
You asked the Plan to pay for these services. You say that you were not aware that these physicians would not 
be covered. The Plan denied your request. The Plan says the providers indicate they told you these services 
would not be covered at no charge and you did not have prior authorization for out of network care. 
 
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 providers in this case are not network providers 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 physician services 
provided from August 13, 2020, to September 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network acupuncture services provided on June 8, 
2020.  
 
You asked the Plan to pay for this service. You say that this service should be covered by the Plan. The Plan 
denied your request. The Plan says you did not have prior authorization for out of network care. 
 
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 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 out of network acupuncture 
services provided on June 8, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested drug does not meet step therapy criteria. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Euflexxa. Our reviewer says that the 
documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found the enrollee has pain related to osteoarthritis of the left knee, diagnosis confirmed by orthopedic 
evaluation. The enrollee has failed conservative treatment. The documentation does not support that the 
enrollee has tried and failed Orthovisc and Monovisc. The documentation does not support that the plan's 
required drugs would likely be less effective and/or likely have adverse effects for the enrollee. Therefore, the 
enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: Other
Decision: Favorable

We decided that the Plan has to pre-approve a heavy duty wheelchair. 
 
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied 
your request. The Plan says that the notes from the doctor do not show why this wheelchair is needed. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The plan did not substantiate the denial for the heavy duty wheelchair with 
objective medical record. The case file appears to indicate that the plan did have some records to use for their 
denial. These records were not provided to MAXIMUS for review. Therefore, we decided that the Plan has to 
pre-approve a heavy duty wheelchair.  
 
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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a 
participating provider on September 2, 2020. 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that you were told that your 
copayment would be $175. The Plan denied your request. The Plan says the correct copayment 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). Your contract with the Plan clearly says that you must pay a $225 
copayment for outpatient hospital services/outpatient surgery.  
 
You have been asked to pay a $225 copayment for an outpatient surgery. The surgery that was provided was 
provided by a hospital; therefore, the correct copayment has been applied. An outpatient surgery falls within 
the outpatient hospital services/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 
copayment for an outpatient surgery provided by a participating provider on September 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the catheter supplies (A4352) provided on May 11, 2020 by 
an out of network (OON) provider. 
 
You asked the Plan to pay for catheter supplies. You say that this is supported in the records. The Plan denied 
your request. The Plan says this was not authorized. 
 
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 catheter supplies (A4352) provided on May 
11, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prochlorperazine. 
 
You asked the Plan to pre-approve Prochlorperazine. The Plan denied your request. The Plan says 
Prochlorperazine to be taken at home is not covered under the Part B benefit. 
 
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 Prochlorperazine.  
 
Benefits for Prochlorperazine 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a polysomnography as identified by CPT code 95810. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
service duplicates the approved study. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 95810 is polysomnography; age 6 years or older, sleep 
staging with 4 or more additional parameters of sleep, attended by a technologist. We find that CPT code 
95810 is not the most comprehensive code for the necessary services. The file shows that the Plan has pre-
approved the necessary services with the most comprehensive code that describes the services to be performed. 
Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a polysomnography as identified by CPT code 95810.