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

 
We decided that the Plan does not have to waive the copayments for two specialist office visits (99204) and an 
x-ray exam of the knee (73562) provided on September 4, 2020 and October 2, 2020. 
 
You asked the Plan to waive the copayments for two specialist visits and an x-ray exam. You say that you 
should not have to pay for these services because you were dissatisfied with the care provided. The Plan denied 
your request. The Plan says office visits with a specialist have a $35 copay per visit and x-ray exams provided 
in an outpatient setting have a $15 copay. 
 
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 $15 
copay for outpatient diagnostic x-ray exams and a $35 copay for physician specialist services.  
 
You have been asked to pay $70 for two specialist visits ($35 x 2) and $15 for an x-ray exam. Specialist visits 
fall within the physician/practitioner services benefit category, and an x-ray exam 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 copayments for two specialist office visits 
(99204) and x-ray exam of the knee (73562) provided on September 4, 2020 and October 2, 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF care. You say that the stay is medically necessary.The Plandenied your request. The Plan says the stay 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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for weakness and a urinary tract infection. Medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multipletherapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.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-approveacute IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay fora chest X-ray providedon February 5, 2020.You asked the Plan to pay forthe chest X-ray. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan.The Plan did not pre-approve the servicesat 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 fora chest X-ray provided on February 5, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay 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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for surgical treatment of a hip fracture after a fall. Medical conditions are stable. There are no 
medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for 
physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There 
is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the implant supported crown provided on November 12, 
2020. 
 
You asked the Plan to pay for the implant supported crown. You say that you needed the implant in order to 
chew properly. The Plan denied your request. The Plan says this service is 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 
implant supported crown provided on November 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the polycarbonate lenses (V2784) provided October 13, 
2020. 
 
You asked the Plan to pay for the polycarbonate lenses. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says the enhancement is not covered under your 
supplemental benefit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the polycarbonate lenses have not been met. Therefore, we decided that the Plan does not have to pay for the polycarbonate lenses (V2784) provided October 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided on February 11, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. 
The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the 
rendering facility is also out-of-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 had network providers 
available who could have provided 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 on February 11, 2020 
by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on September 23, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. 
The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the 
referring provider is also out-of-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 had network providers 
available who could have provided 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 on September 23, 
2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on July 20, 2020. 
 
You asked the Plan to pay for the genetic testing. 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. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The genetic testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover 
this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the genetic 
testing provided on July 20, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Opdivo, Yervoy, Ondansetron Oral, Epoetin Alfa-
EPBX, Zarxio for the enrollee. 
 
 
You asked the Plan to pre-approve the drugs. You say that this is medically necessary. The Plan denied your 
request. The Plan says use of this drug regimen is not supported by the cancer compendia, accepted cancer 
journals, or relevant medical guidelines. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 drugs. Our reviewer says that the 
requested drugs are not medically reasonable or necessary. Our physician reviewer found the combination of 
nivolumab (Opdivo)/ipilumumab (Yervoy) is not FDA approved for the treatment of pancreatic cancer, 
supported by major drug compendia or the medical literature. The NCCN Guidelines does not even mention 
this as an option. The enrollee has not additional testing to suggest benefit from immunotherapies. The service 
was not reasonable or medically 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 drugs have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Opdivo, Yervoy, Ondansetron Oral, Epoetin Alfa-EPBX, Zarxio for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychiatric services rendered on March 4, 2019. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for these services was not filed until October 21, 2020. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for the psychiatric services rendered on March 4, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the shoe insert (CPT Code L3020). 
 
You asked the Plan to pre-approve foot orthotics. You say that you experience pain without foot inserts. The 
Plan denied your request. The Plan says the Medicare rules have not been met. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve the shoe insert (CPT Code L3020).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. 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 LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where she is currently receiving care. There are no services available at the LTACH that the 
enrollee requires that are not available at the health care setting being offered by the health plan. The requested 
LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of 
the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an E0784 External Ambulatory Infusion Pump for Insulin. 
 
You asked the Plan to pre-approve the insulin pump. You say that the device is medically necessary. The Plan 
denied your request. The Plan says that did not make a determination in a timely fashion, so the appeal was 
forwarded to us. 
 
The Plan follows Medicare rules. Medicare rules say that the enrollee with diabetes has been on a pump prior 
to enrollment in Medicare and has documented frequency of glucose self-testing an average of at least 4 times 
per day during the month prior to Medicare enrollment meets coverage.  
 
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 insulin pump. Our reviewer says 
that you need this medical item. Our physician reviewer found you have been taught how to use the pump. The 
enrollee was testing their blood sugar four times a day as shown in Criterion B. The documentation shows the 
A1C was 8% in January, and in combination with other factors, the criteria were met for the insulin pump. 
 
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 insulin pump have been met. Therefore, we decided that the Plan has to pre-
approve an E0784 External Ambulatory Infusion Pump for Insulin.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xeljanz Xr Tab 11 mg. 
 
You asked the Plan to pre-approve Xeljanz Xr Tab 11 mg. You say that the medication is necessary. The Plan 
denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit or a separate 
pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
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 Xeljanz Xr Tab 11 mg.  
 
Benefits for Xeljanz Xr Tab 11 mg 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Toujeo Solostar for the enrollee.
You asked the Plan to pre-approve this drug. You say that the enrollee needs this to treat her Type 2 diabetes mellitus. The Plan denied your request. The Plan says that this 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 Toujeo Solostar for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and the cone beam CT 
(D0364) provided on July 29, 2020. 
 
You asked the Plan to pay for the dental services. You say that the dentist took an x-ray of your whole mouth. 
You say that you do not know why. You also say that you are being charged $97.50. The Plan denied your 
request. The Plan says 1 limited oral evaluation is covered every plan years. The Plan says that the frequency 
limit for this service has been exceeded. The Plan also says that cone beam CT is not listed as a covered 
service. 
 
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 limited oral 
evaluation per plan year has been exceeded. The record shows that the Plan paid for the limited oral evaluation 
that you received on August 3, 2020. Additionally, the cone beam CT is not among those covered under this 
benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) and 
the cone beam CT (D0364) provided on July 29, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on July 19, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that the medics treated the enrollee in place and 
triaged to BLS. 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 19, 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 July 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on December 12, 2019.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says prior authorization was required for services with a non-contracted provider.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the physician's services.We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided on December 12, 2019.