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

 
We decided that the Plan has to pre-approve an attended polysomnogram (PSG), also known as a sleep study. 
 
You asked the Plan to pre-approve the PSG. You say that the enrollee requires this testing due to his comorbid 
conditions. The Plan denied your request. The Plan says that there is no evidence of any comorbid conditions 
like Congestive Heart Failure, Neuromuscular disease or COPD (Chronic Obstructive Pulmonary Disease). As 
such, criteria are not met. 
 
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 PSG. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found an attended PSG with PAP titration is considered reasonable and medically necessary.  This patient has 
known OSA and is compliant with PAP therapy.  However, the patient is having non-restful sleep and 
tachycardia in the morning, despite already being on auto-PAP. The compliance report indicates an elevated 
AHI, suggesting his OSA is inadequately treated with the current PAP therapy.  A formal PAP titration is 
needed, which cannot be done as part of a home PSG. 
 
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 PSG have been met. Therefore, we decided that the Plan has to pre-approve 
an attended polysomnogram (PSG), also known as a 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a post and core in addition to crown (D2952). 
 
You asked the Plan to pre-approve the post and core. You say that you would like this reconsidered. 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 pre-approve a 
post and core in addition to crown (D2952).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services for a COVID-19 antibody test provided 
on April 28, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says this 
provider has opted out of Medicare and the services are not emergent or urgent. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This 
provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
physician's services for a COVID-19 antibody test provided on April 28, 2020.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a sleeve gastrectomy bariatric surgery. 
 
You asked the Plan to pre-approve the bariatric surgery. You say that it is felt that this treatment is medically 
necessary. The Plan denied your request. The Plan says that documentation shows that the enrollee was unable 
to lose weight following the dietary program and gained weight instead. As such, the criteria for this surgery 
are not met. 
 
The Plan follows Medicare rules. Medicare rules say that bariatric surgery is considered reasonable and 
necessary when the above criteria are met.  
 
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 bariatric surgery. Our reviewer says 
that the requested procedure is shown to be medically reasonable and necessary. Our physician reviewer found 
the enrollee is a 55-year-old woman with a long-standing history of Morbid (severe) obesity due to excess 
calories, as well as type 2 diabetes mellitus, atrial fibrillation, and congestive heart failure.  The enrollee has a 
BMI greater than 35, has at least one co-morbidity related to obesity, and has previously been unsuccessful 
with medical treatment for obesity. The enrollee has been provided with knowledge and tools needed to 
achieve such lifelong lifestyle changes, exhibits understanding of the needed changes, and is demonstrated to 
clinicians involved in her care to be capable and willing to undergo the changes. The enrollee has made a 
diligent effort to achieve healthy body weight with such efforts described in the medical record and certified by 
the operating surgeon. The patient has failed to maintain a healthy weight despite adequate participation in a 
structured dietary program overseen by her Physician (MD). 
 
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 bariatric surgery have been met. Therefore, we decided that the Plan has to 
pre-approve a sleeve gastrectomy bariatric surgery.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the immediate mandibular partial denture provided on 
October 31, 2019. 
 
You asked the Plan to pay for the immediate mandibular partial denture. You say that you were prescribed 
medicines which dried out your mouth and caused you to need dentures. The Plan denied your request. The 
Plan says the dental benefit does not cover dentures. 
 
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 
immediate mandibular partial denture provided on October 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require 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 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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve blocks for the knees. 
 
You asked the Plan to pre-approve the blocks. You say that this is medically necessary. The Plan denied your 
request. The Plan says the effectiveness of this request has not been established. 
 
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 blocks. Our reviewer says that the 
requested blocks are not considered medically reasonable and necessary in this case. Our physician reviewer 
found this is an experimental and investigational procedure that is the subject of on-going clinical trials. You 
are not enrolled in a clinical trial.  Therefore, the requested procedure is deemed not medically reasonable or 
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 blocks have not been met. Therefore, we decided that the Plan does not have 
to pre-approve genicular nerve blocks for the knees.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a K0823 Group 2 Power Wheelchair (PWC) and 
accessories for the enrollee. 
 
You asked the Plan to pre-approve the requested power wheelchair and accessories. You say that the requested 
power wheelchair is medically necessary. The Plan denied your request. The Plan says Medicare coverage 
criteria are not met. 
 
The Plan must follow Medicare rules. Medicare has specific coverage criteria for power wheelchairs. 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 requested power wheelchair and accessories. Our 
reviewer says that Medicare coverage criteria are not met. Our physician reviewer found the medical records do 
not show the enrollee is unable to complete daily activities in the home. The enrollee is currently using a 
walker in the home. The enrollee has not tried and failed a manual wheelchair in the home. Power wheelchairs 
are not covered for use outside of the home. Medicare coverage criteria are 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 the requested power wheelchair and accessories have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a K0823 Group 2 Power Wheelchair (PWC) and accessories for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CPAP cleaner. 
 
You asked the Plan to pre-approve the cleaner. You say that it is inconvenient to have to wash the CPAP all the 
time. The Plan denied your request. The Plan says this is a convenience item that is not primarily used to treat a 
medical condition. 
 
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 CPAP cleaner.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transportation you received 
on August 13, 2019. 
 
You asked the Plan to waive the copayment. The Plan denied your request. The Plan says you are responsible 
for the copayment. 
 
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 $150 
copayment for ground ambulance transportation.  
 
Review of the file shows that you were provided ambulance transportation on August 13, 2019. You have been 
asked to pay a $150 copayment for the services. The services fall within the ambulance services benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for the ambulance transportation you received on 
August 13, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an upper airway stimulation device. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says the criteria has not been met. 
 
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 device. Our reviewer says that the 
requested device is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the review indicates that the enrollee's Body Mass Index (BMI) is 35.86. The review has determined that 
the enrollee does not meet all of the criteria above. 
 
 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an upper airway stimulation device.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services (A0429) received. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that the ambulance company 
informed you that costs were waived if the ambulance services were used due to coronavirus. The Plan denied 
your request. The Plan says you were charged this cost sharing correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $225 
copayment for each ambulance trip. You had 1 ambulance trip. The Plan charged you $225 for these services. 
The case record documents that the Plan?s policy regarding cost-sharing waivers related to COVID-19 or 
coronavirus treatment does not apply to emergency, urgent, and ambulance services. 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 ambulance services.  
 
Your complaint about receiving erroneous or misleading information from the provider is not a valid appeal for 
medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does 
not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the lung biopsy you had. 
 
You asked the Plan to waive the copayment for the lung biopsy. You say that this biopsy was unnecessary and 
resulted in you needing heart surgery. The Plan denied your request. The Plan says you were charged this 
copayment correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $175 
copayment for outpatient hospital surgery.  
 
You have been asked to pay a $175 copayment for the lung biopsy. The lung biopsy falls within the outpatient 
hospital surgery benefit category. This amount applies regardless of your satisfaction with the care you 
received. 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 lung biopsy you had.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99308) and removal of 
skin and tissue first 20 sq. cm or less (11042) provided on June 5, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for subsequent nursing facility care and removal of skin and tissue. You say that the 
services were medically necessary. The Plan denied your request. The Plan says prior authorization must be 
obtained for services rendered by an out-of-network 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 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 subsequent nursing facility care (99308) and 
removal of skin and tissue first 20 sq. cm or less (11042) provided on June 5, 2020 by an out of network 
(OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the Eylea injections you received. 
 
You asked the Plan to waive the coinsurance for the Eylea injections. You say that you were never told about 
this coinsurance obligation. The Plan denied your request. The Plan says you were charged this coinsurance 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare Part B drugs.  
 
You have been asked to pay 20% coinsurance for the Eylea injections. The Eylea injections falls within the 
Medicare Part B drugs benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the Eylea 
injections you received.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the vision care provided to you. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that this is a non-
participating provider. 
 
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 contends that the requested provider is non-participating. However, an 
NPI search indicates that this provider is a Medicare participant. It should also be noted that the enrollee has a 
PPO plan, which covers out-of-network services with applicable cost sharing. Therefore, we decided that the 
Plan has to pay for the vision care provided to you.  
 
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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mental health services provided. 
 
You asked the Plan to pay for the mental health services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require 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 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 mental health services provided.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit with electrocardiogram (99214, 93000) 
provided, by an out of network (OON) provider. 
 
You asked the Plan to pay for the office visit with electrocardiogram. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization was 
not obtained by the facility or the provider; therefore, payment has been correctly denied. 
 
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 office visit with electrocardiogram (99214, 
93000) provided, by an out of network (OON) provider.