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

 
We decided that the Plan does not have to pre-approve a Positron Emission Tomography (PET) scan of the 
brain. 
 
You asked the Plan to pre-approve PET scan. You say that you need this testing. The Plan denied your request. 
The Plan says the denial of authorization for this service is correct, because you do not meet the Medicare 
criteria for this PET scan. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 PET scan. Our reviewer says that you 
do not meet the Medicare criteria for the requested PET scan. Our physician reviewer found there is no 
documentation of you meeting criteria for both Alzheimer's Disease and Fronto-temporal Dementia (FTD). 
You do not have an indication for which this PET scan can be covered at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PET scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a Positron Emission Tomography (PET) scan of the brain.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you would like reconsideration because these 
inserts will relieve wound pressure. The Plan denied your request. The Plan says this item is not a covered 
benefit. 
 
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 foot orthotics.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 4 additional physical therapy visits. 
 
You asked the Plan to pre-approve 4 additional physical therapy visits. You say that you have progressed and 
are getting back to a functional state. You say that you want to continue physical therapy to work on range and 
mobility. The Plan denied your request. The Plan says additional visits are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 4 additional physical therapy visits.. 
Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent 
deterioration of the enrollee's condition. Our physician reviewer found that you have had extensive therapy for 
this condition. Our reviewer says that the unique skills of a professional therapist are not required to safely and 
effectively provide ongoing treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 4 additional physical therapy visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 4 additional physical therapy visits.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional physical therapy visits. 
 
You asked the Plan to pre-approve 10 additional physical therapy visits. You say that the enrollee has made 
continuous progress in physical therapy. You say that the enrollee would benefit from continued gait/balance 
training and strengthening to improve walking distance. The Plan denied your request. The Plan says additional 
visits are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 10 additional physical therapy visits. 
Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent 
deterioration of the enrollee's condition. Our physician reviewer found that the enrollee has had prior therapy 
and her current deficits do not require the unique skills of a professional therapist to safely and effectively 
provide ongoing treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 10 additional physical therapy visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 10 additional physical therapy visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete mandibular denture (D5120). 
 
You asked the Plan to pre-approve the complete mandibular denture. You say that you need dentures because 
of your health issues. The Plan denied your request. The Plan says this service is not covered under your 
benefit package. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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 pre-approve a 
complete mandibular denture (D5120).
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to reduce the coinsurance for injections. We decided that the Plan does not have 
to waive the coinsurance for injections.  
 
You asked the Plan to waive the coinsurance for injections. You say that you do not agree with this 
coinsurance. The Plan says that the correct coinsurance has been applied. 
 
We decided that the Plan has to reduce the coinsurance for injections.  
 
The Plan cannot ask you to pay more than a 20% coinsurance of the allowed amount for injections. The total 
allowed amount is 580.02. The total amount you are being asked to pay is $116.00 ($580.02 x 20% = $116.00). 
 
We also decided that the Plan does not have to waive the coinsurance for injections. 
 
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 of the allowed amount for injections. Therefore, we decided that the Plan does not have to waive 
the coinsurance for injections. 
 
 
 
 
 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the brand specific rollator. 
 
 
 
You asked the Plan to pre-approve a brand specific rollator. You say that you need this specific rollator. The 
Plan denied your request. The Plan says this device exceeds your needs and is considered a luxury item under 
Medicare. 
 
The Plan must follow Medicare rules. The rules say for any item to be covered by Medicare, it must 1) be 
eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment 
of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable 
Medicare statutory and regulatory requirements.   
 
The record does not show you would have an adverse medical outcome with a Plan provided rollator. 
Therefore, we decided that the Plan does not have to pre-approve the requested brand specific rollator.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Bevacizumab. 
 
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says that the services are not medically necessary. 
 
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 these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the enrollee has a diagnosis of metastatic 
clear cell renal cancer. The request is for Bevacizumab to be given with Pazopanib on a clinical trial at an 
National Comprehensive Cancer Network (NCCN) designated cancer center. Pazopanib is FDA approved for 
treatment of advanced renal cell cancer; therefore, the enrollee will receive the standard of care and 
Bevacizumab. The services are safe and effective and reasonable and 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 these services have been met. Therefore, we decided that the Plan has to pre-
approve Bevacizumab.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the power seat elevation system (E2300). 
 
You asked the Plan to pre-approve the power seat elevation system. You say that you would like 
reconsideration because this supply is medically necessary. The Plan denied your request. The Plan says the 
power seat elevation is not primarily medical in nature. 
 
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. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve the power seat elevation system (E2300).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on February 5, 2020.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says there is no network deficiency for these services.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 servicesat issue in this appeal. The Plan did not pre-approve the services 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 to the enrollee by an out-of-network provider on February 5, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by out of network provider,You asked the Plan to pre-approve the out-of-network referral. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says there are in-network options available to provide this service.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 pre-approve 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the medical services to be provided by out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown on tooth #30.
You asked the Plan to pre-approve the crown. You say that this service should be covered because they cannot put a crown on a bad tooth. You also say that this tooth is decaying. The Plan denied your request. The Plan says this service is not medically necessary. The Plan also says that the documentation provided does not demonstrate the need for replacement of the existing crown.
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 crown 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 crown. Our reviewer says that the service is not medically necessary. Our physician reviewer found documentation provided does not support the need for the replacement of a crown on tooth #30. 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 crown have not been met. Therefore, we decided that the Plan does not have to pre-approve a crown on tooth #30.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit provided on January 24, 
2020. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you disagree with the charges 
because you are unhappy with the service you received. The Plan denied your request. The Plan says the claims 
were processed correctly and you are being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
copayment for each specialist visit.  
 
You have been asked to pay a $35 copayment for a specialist visit. A specialist visit falls within the 
physician/practitioner services, including doctor's office visits benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for a specialist visit provided on January 24, 2020.  
 
Your quality of care concerns have been handled separately by the health plan. Medicare does not permit 
MAXIMUS to make a decision on this type of complaint.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lower partial denture (D5212).
You asked the Plan to pre-approve a lower partial denture (D5212). You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says you had a partial denture (D5212)
delivered to you in April 2018. The Plan states you are only covered for a partial denture (D5212) once per 60
months.
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 at this time. The contract with the Plan clearly states a mandibular
partial denture coded as D5212 is covered once per 60 months. The file shows that you received a mandibular
partial denture coded as D5212 in April 2018, which is less than 60 months ago. Therefore, we decided that the
Plan does not have to pre-approve a lower partial denture (D5212).
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the inpatient hospital services provided from May 12, 2019 to May 28, 2019.You asked the Plan to pay for the inpatient hospital services. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says that the patient who received these services is not the member of the Plan.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 is stating that they confirmed that the enrollee is not the patient who received these services. However, the Plan has not provided any evidence to show how they confirmed that the enrollee didn't receive the services. We find that the Plan did not substantiate its denial regarding the identity theft.Therefore, we decided that the Plan has to pay for the inpatient hospital services provided from May 12, 2019 to May 28, 2019.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on May 18, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the member 
must receive care from a network provider. In most cases, care the member receives from an out-of-network 
provider will not be covered. Additionally, the services performed are available in-network and no 
documentation that the provider contacted the plan in regards to networking, authorization, or benefits prior to 
office visit. 
 
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 May 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) unit 
rendered on February 18, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a TENS unit is covered for CLBP when specific 
criteria are met. 
 
We looked at the file and Medicare rules. There is no documentation in the submitted file to support that the 
enrollee meets the criteria for the TENS unit. based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the 
transcutaneous electrical nerve stimulation (TENS) unit rendered on February 18, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a balloon sinuplasty. 
 
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 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of chronic 
pansinusitis, hypertrophy of nasal turbinates, deviated nasal septum, and allergic rhinitis. The records do not 
support that the enrollee has been refractory to medical treatment. The balloon sinuplasty is therefore 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a balloon sinuplasty.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from January 21, 2020 to 
January 23, 2020. 
 
You asked the Plan to pay for the home health services. You say that the enrollee's doctor ordered an aide to 
come to the apartment twice a day. You say none of the in-network providers would provide home health aide 
services in the city where the enrollee lives. The Plan denied your request. The Plan says this provider is a non-
participating provider with the Plan and not certified with Medicare and there are certified providers available 
for the enrollee to utilize. 
 
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 services 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 home health services provided from 
January 21, 2020 to January 23, 2020.