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

 
We decided that the Plan has to pre-approve computed tomography angiography of the chest for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that imaging is not supported without results of a physical exam that shows a reason for 
the imaging. 
 
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 services. Our reviewer says that the 
requested services are medically reasonable or necessary. Our physician reviewer found based on the records, 
the enrollee is a current smoker with COPD. Since she is age 55-74 with current smoking and no life limiting 
conditions annual screening with low dose helical chest CT scan is recommended by the US preventative task 
force guidelines. Studies have demonstrated improved outcomes with screening chest CT scanning in this 
patient subset compared to screening with chest x-ray alone. Therefore the documentation does support the 
medical necessity for a screening chest CT scan. 
 
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 services have been met. Therefore, we decided that the Plan has to pre-
approve computed tomography angiography of the chest for the enrollee.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the hospital observation services (G0378) 
provided from February 17, 2020, to February 20, 2020. 
 
You asked the Plan to waive the copayment for the hospital observation services. You say that you disagree 
with the copayment due to the services you received. The Plan denied your request. The Plan says this 
copayment has applied correctly in this case. 
 
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 outpatient hospital observation.  
 
You have been asked to pay a $250 copayment for the hospital observation services. The services provided fall 
within the outpatient hospital observation 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 hospital observation services (G0378) provided from February 17, 2020, to February 20, 2020.  
 
Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus 
Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the 
appropriate Quality Improvement Organization for further review.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ABPM (CPT Code A4670). 
 
You asked the Plan to pre-approve the ABPM. You say that this should be covered for you because your blood 
pressure can be very low and very high at times. The Plan denied your request. The Plan says Medicare does 
not cover automatic blood pressure monitors. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only 
for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require 
ABPM to confirm a diagnosis of hypertension.  
 
Medicare does not cover automatic blood pressure monitors. Therefore, we decided that the Plan does not have 
to pre-approve ABPM (CPT Code A4670).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician visit (99350) provided on July 6, 2020. 
 
You asked the Plan to pay for the physician visit. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the services were non-emergent and there were network providers available. 
 
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 services at issue in this appeal. 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 the physician visit (99350) provided on July 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services (D0150, D0274, D0330, D0220, D0230) 
provided on July 22, 2019, by an out of network (OON) provider. 
 
You asked the Plan to pay for the dental services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says services performed by an OON provider 
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. 
 
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 dental services (D0150, D0274, D0330, 
D0220, D0230) provided on July 22, 2019, by an out of network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Supartz. 
 
You asked the Plan to pre-approve Supartz. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has 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 Supartz. Our reviewer says that the 
medication is not medically necessary. Our physician reviewer found the enrollee has not trialed 
viscosupplemental treatments such as Orthovisc and Synvisc/Synvisc One. Step therapy, as outlined by the 
plan, requires these be trialed first. The documentation does not outline contraindications or reasons these 
medications were not considered. Without the support of the documentation, Supartz is not approved as step 
criteria is not 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 Supartz have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Supartz.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220), retreatment of 
previous root canal therapy (D3348), consultation (D9310), five localized deliveries of antimicrobial agents 
(D4381 x5), and drugs or medicaments dispensed in the office for home use (D9630) provided from June 2, 
2020, to June 24, 2020. 
 
You asked the Plan to pay for the first intraoral periapical x-ray, retreatment of previous root canal therapy, 
consultation, localized deliveries of antimicrobial agents, and drugs or medicaments. You say that you were 
advised that these services would be covered, and later were told they were not covered. The Plan denied your 
request. The Plan says the retreatment of previous root canal therapy, localized deliveries of antimicrobial 
agents, and drugs or medicaments are non-covered dental services. The Plan also says that you exceeded the 
maximum benefits for the first intraoral periapical x-ray and consultation. 
 
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 retreatment of previous root canal 
therapy (D3348), localized delivery of antimicrobial agents (D4381), and drugs or medicaments dispensed in 
the office for home use (D9630) are not among those covered under this benefit. The contract clearly states that 
first intraoral periapical x-ray (D0220) and consultation (D9310) are each limited to 1 per year. The record 
shows that you received a first intraoral periapical x-ray (D0220) and consultation (D9310) on May 29, 2020, 
and your first intraoral periapical x-ray (D0220) and consultation (D9310) benefits had been exhausted. 
Therefore, we decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220), 
retreatment of previous root canal therapy (D3348), consultation (D9310), five localized deliveries of 
antimicrobial agents (D4381 x5), and drugs or medicaments dispensed in the office for home use (D9630) 
provided from June 2, 2020, to June 24, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on January 18, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were treated in place by the medics. 
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 January 18, 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 provided on January 18, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve the complete lower dentures (D5120). 
 
You asked the Plan to pre-approve the complete lower dentures. You say that the services requested are 
medically necessary. The Plan denied your request. The Plan says that you have exhausted your benefit for the 
services requested. 
 
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 complete 
denture - mandible 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 complete lower dentures. Our 
reviewer says that there was a lower partial denture made in 2019, but due to rampant caries the remaining 
teeth need to be removed and a full denture fabricated.  The Plan restricts services as to replacement of a 
prosthetic service to 60 months.  For the lower partial denture, the 60-month restriction applies to either 
D5212, D5214, D5226, or D5281. The requested denture code is D5120 and is not included in the 60-month 
restriction. Given the need to remove the failing teeth and place a full denture, the requested service would be 
considered medically necessary and the benefit would not be considered exhausted. 
 
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 complete lower dentures have been met. Therefore, we decided that the Plan 
has to pre-approve the complete lower dentures (D5120).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on August 23, 2020 by an out 
of network provider. 
 
You asked the Plan to pay for the medical services. You say that the enrollee is unable to have the correct 
doctor sign their orders. The Plan denied your request. The Plan says you did not request 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 services at issue in this appeal. 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 the medical services provided on August 23, 2020 by an out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Neuronode switch for a speech generating device. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Therefore, we 
decided that the Plan does not have to pre-approve a Neuronode switch for a speech generating device.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Crestor tablets. 
 
You asked the Plan to pre-approve self-administered drug. You say that the enrollee has tolerance to this brand 
of drug. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, 
because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare 
Part D prescription drug benefits. 
 
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 Crestor tablets.  
 
Benefits for self-administered drug 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: DME/ Orthotics
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 a cost-sharing reduction for Novolog. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an ultrasound duplex scan, 
echocardiogram, and office visit provided. 
 
You asked the Plan to waive the copayments for duplex scan, echocardiogram, and office visit. You say that 
you were under the impression that these services would be billed with a single copayment. The Plan denied 
your request. The Plan says the copayment amounts you are being charged are correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $55 
copayment for duplex scan, $55 copayment for echocardiogram, and $50 copayment for specialist visit. Your 
total copayment obligation is therefore $160. 
 
You have been asked to pay $55 copayment for duplex scan and echocardiogram and $50 copayment for 
specialist visit. Duplex scan, echocardiogram, and office visit fall within the "Outpatient Diagnostic Tests and 
Therapeutic Services and Supplies" and "Physician/Practitioner Services, Including Doctor's Office Visits" 
benefit categories. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayments for an ultrasound duplex scan, 
echocardiogram, and office visit provided.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve epidural injection (62321). 
 
You asked the Plan to pre-approve the injection services. You say that the requested epidural injections is 
medically necessary and beneficial to the enrollee. The Plan denied your request. The Plan says that the records 
do not support that the enrollee meets the criteria. 
 
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 injection services. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found the degree of pain relief is documented in the application and the patient has failed 
conservative therapy. The request is 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 the injection services have been met. Therefore, we decided that the Plan has to 
pre-approve epidural injection (62321).  
 
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: 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 the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 the complexity of your nursing, medical and rehabilitation needs require an acute 
hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical status currently 
does not require intensive physician and nursing supervision in an IRF. While you may benefit from additional 
physical and occupational therapy the documentation does not support that you require this therapy on an IRF 
level. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on June 25, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the drug testing services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services provided are not a covered benefit. 
 
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 drug testing services provided on June 25, 
2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home INR monitoring. 
 
You asked the Plan to pre-approve the monitoring. You say that this is medically necessary. The Plan denied 
your request. The Plan says documentation is required showing a face-to-face education program in 
anticoagulation management and demonstration of the correct use of the device. 
 
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 the monitoring. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found in this case ,there is no documentation of a face-to-face educational program on anticoagulation 
management and no documentation that the enrollee knows of the correct use of the device prior to its use in 
the home. The review has determined that the enrollee does not meet the above criteria for these 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 the monitoring have not been met. Therefore, we decided that the Plan does not 
have to pre-approve home INR monitoring.