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

 
We decided that the Plan has to pre-approve angiography of extremities (75710). 
 
You asked the Plan to pre-approve angiography of extremities. You say that this is medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says that the requested services do not meet 
medical necessity 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 angiography of extremities. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found that the documentation supports the medical necessity of the procedure in 
question.  While the medical record has conflicting descriptions of the patients symptoms, the computed 
tomography angiography scan, as an objective study, demonstrates what appears to be significant narrowing of 
the common iliac arteries bilaterally particularly on the left, where the common iliac artery stent measures 3.1 
mm x 3.5 mm-this is compared to the external iliac artery measuring 6 mm x 7 mm.  
 Additionally, it was determined that the patient had such significant iliac disease that the percutaneous heart 
valve replacement procedure had to be performed through an alternative, infraclavicular (arm) approach. The 
providers have documented that they believe the patient is having lifestyle limiting claudication. Therefore, as 
there is sufficient objective information corroborating significant aortoiliac artery occlusive disease, the plan 
for angiography and possible intervention is both 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 angiography of extremities have been met. Therefore, we decided that the Plan 
has to pre-approve angiography of extremities (75710).  
 
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 Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for hyperbaric oxygen therapy provided on 
February 10, 2022. 
 
You asked the Plan to waive the copayment for the hyperbaric oxygen therapy. You say that you would like 
this service covered. The Plan denied your request. The Plan says the copayment was applied 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 services.  
 
You have only been asked to pay a $100 copayment for the hyperbaric oxygen therapy which is less than the 
standard $175 copayment. The hyperbaric oxygen therapy falls within the Outpatient hospital 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 hyperbaric oxygen therapy 
provided on February 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an office visit provided on January 7, 2022. 
 
You asked the Plan to waive the deductible for an office visit. You say that you can find no reason why this 
claim was not paid, and your deductible has already been paid. The Plan denied your request. The Plan says 
you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $110 deductible for all items and services except those specifically 
excluded by the Plan contract.  
 
You have been asked to pay $96.77 for an office visit. An office visit falls within the benefit category 
physician/practitioner services, including doctors office visits. The Plan has followed Medicare rules by 
clearly disclosing in the contract that there is a $110 deductible which applies to physician/practitioner 
services, including doctors office visits. This cost sharing is a contractual obligation that had not been met at 
the time an office visit was received on January 7, 2022. Therefore, we decided that the Plan does not have to 
waive the deductible for an office visit provided on January 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services provided on November 29, 2021. 
 
You asked the Plan to pay for the genetic testing services. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says this claim has not been billed correctly 
as required by Medicare billing regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the genetic testing services provided 
on November 29, 2021, have been met. In this case, no documentation has been provided from the enrollees provider indicating why the testing was ordered. Therefore, we decided that the Plan does not have to pay for 
the genetic testing services provided on November 29, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Supartz. 
 
You asked the Plan to pre-approve Supartz. You say that your knee is in pain. The Plan denied your request. 
The Plan says the denial of authorization for this drug is correct, because the Plan requires a trial of Orthovisc, 
Synvisc, or Synvisc-One before it will approve Supartz. 
 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 you do 
not meet the Medicare criteria for a step therapy exception for Supartz. Our physician reviewer found you have 
not tried and failed the Plan's preferred drugs of Orthovisc, Synvisc, or Synvisc-One. The record does not show 
that these drugs would likely be less effective and/or have adverse effects for you. 
 
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 use of Supartz.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an intravenous (IV) infusion therapy 
procedure provided on November 1, 2021. 
 
You asked the Plan to waive the copayment for IV infusion therapy. You say that you were told that this would 
be covered at 100%. The Plan denied your request. The Plan says the copayment amount you are being charged 
is 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 $250 
copayment for covered services provided at an outpatient hospital.    
You have been asked to pay the allowed amount of $193.16, which is less than the $250 copayment for IV 
infusion therapy. IV infusion therapy falls within the Outpatient Surgery and Other Medical Services Provided 
at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for an intravenous (IV) infusion therapy procedure provided on November 1, 2021.  
 
Your complaint regarding receiving inaccurate information about the cost-share for this service is considered to 
be a grievance. MAXIMUS does not have the jurisdiction to address grievances. Please contact the Plan for 
more information about your grievance.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care visit provided on August 18, 
2021. 
 
You asked the Plan to waive the copayment for the urgent care visit. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied 
correctly based on the services provided. 
 
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 $30 
copayment for Urgently Needed Services.  
 
 
  You have been asked to pay a $30 copayment for the urgent care visit. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for an urgent care visit provided on August 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitoring (CGM) 
sensor (K0553). 
 
You asked the Plan to pre-approve a Freestyle Libre CGM sensor. You say that the enrollee has type 2 diabetes 
and is currently being treated with the requested product. The Plan denied your request. The Plan says the 
enrollee does not meet prior authorization criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections and require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a Freestyle 
Libre CGM sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre continuous glucose monitoring (CGM) sensor (K0553).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for diabetic shoes and inserts provided on 
January 7, 2022. 
 
You asked the Plan to waive the deductible for diabetic shoes and inserts. You say that these are medically 
needed supplies so they should be covered. The Plan denied your request. The Plan says the deductible applied 
is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $1000 deductible which applies to out-of-network services. 
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category Diabetes 
self-management training, diabetic services and supplies. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $1000 deductible which applies to out-of-network services. This cost 
sharing is a contractual obligation that had not been met at the time diabetic shoes and inserts were received on 
January 7, 2022. 
 
 
 
  
 Therefore, we decided that the Plan does not have to waive the deductible for diabetic shoes and inserts 
provided on January 7, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting 
on February 4, 2022. 
 
You asked the Plan to pay for the self-administered drugs. You say that you did not receive self-administered 
drugs during your encounter. The Plan denied your request. The Plan says the drugs you received are 
considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D 
prescription drug plan. The Plan also says the drugs you received are not covered under Medicare 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 pay for the self-administered drugs 
provided in an outpatient setting on February 4, 2022.  
 
Benefits for the self-administered drugs 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the hyperbaric oxygen therapy provided on 
February 4, 2022. 
 
You asked the Plan to waive the copayment for the hyperbaric oxygen therapy. You say that you would like 
this service covered. The Plan denied your request. The Plan says the copayment was applied 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $175 copayment for outpatient hospital services.  
 
You have only been asked to pay a $100 copayment for the hyperbaric oxygen therapy which is less than the 
standard $175 copayment. The hyperbaric oxygen therapy falls within the Outpatient hospital 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 hyperbaric oxygen therapy 
provided on February 4, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on January 19, 
2022. 
 
You asked the Plan to waive the copayment for the outpatient surgery. You say that you were not aware you 
would have a copayment. The Plan denied your request. The Plan says the copayment was applied 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 $395 
copayment for in-network outpatient hospital surgery services.  
 
You have been asked to pay $395 for the outpatient surgery. The outpatient surgery falls within the Outpatient 
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 outpatient surgery provided on January 19, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee disarticulation (or through knee), molded socket, 
single axis knee endoskeletal system (L5312), an addition to a lower extremity, above knee, flexible inner 
socket (L5651), an endoskeletal knee-shin system, single axis, fluid swing and stance phase control (L5828), an 
endoskeletal, knee-shin system, stance flexion feature, adjustable (L5845) and an all-lower extremity 
prosthesis, flex-walk system (L5981). 
 
You asked the Plan to pre-approve replacement prosthesis with components. You say that you need a custom 
fabricated endoskeleton knee disarticulation definitive prosthesis that is reasonable and necessary to maintain 
your functional level for a period of 3-5 years and who is motivated to ambulate and continue with your 
activities of daily living. The Plan denied your request. The Plan says the request for replacement prosthesis 
with K3 components do not meet Medicare criteria as reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say in the event of a claim review, information contained 
directly in the contemporaneous medical record is the source required to justify payment except as noted 
elsewhere for prescriptions and CMNs. 
 
The record does not contain a valid physician order, or relevant medical records which support medical 
necessity for the supplies provided in this case. The record shows that the providers note from January 11, 
2022, state that you are doing well with your prosthesis. The records also show that there is no reason why you 
require a new prosthesis. Therefore, we decided that the Plan does not have to pre-approve a knee 
disarticulation (or through knee), molded socket, single axis knee endoskeletal system (L5312), an addition to a 
lower extremity, above knee, flexible inner socket (L5651), an endoskeletal knee-shin system, single axis, fluid 
swing and stance phase control (L5828), an endoskeletal, knee-shin system, stance flexion feature, adjustable 
(L5845) and an all-lower extremity prosthesis, flex-walk system (L5981).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from 
March 12, 2021, to March 17, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital care. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied 
correctly based on the services provided. 
 
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 $200 
copayment per day for days 1-5 of Inpatient hospital care.  
 
 
  You have been asked to pay a $1,000 copayment for 5 days of inpatient hospital care. the inpatient hospital 
care falls within the Inpatient hospital care 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 inpatient hospital care provided from March 12, 2021, to March 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the requested device. You say that you need to check if your glucose is too 
low. The Plan denied your request. The Plan says you are not insulin-treated. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 
 We looked at the file and Medicare rules. The documentation does not indicate that you perform blood glucose 
testing at least four times per day, use insulin with at least three daily injections, or require frequent self-
adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided 
that Medicare rules for coverage of the requested device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a continuous glucose monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 10, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network and there was no pre-
authorization request. 
 
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 an office visit provided on August 10, 2021 by an 
out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
requested setting is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 services. Our physician 
reviewer found that the record indicates the enrollee has chronic hypercarbic respiratory failure from chronic 
obstructive pulmonary disease. The record does not indicate that the enrollee has failed BiPAP therapy. The 
provided primary source documentation does not contain sufficient detailed information in the medical record 
to justify the treatment selected. The elements of the coverage criteria are not satisfied. 
 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 services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator.