Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a bone scan provided on December 6, 
2021. 
 
You asked the Plan to reduce the copayment for a bone scan. You say that you were told your copayment 
would only be $110. 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 
copayment for nuclear medicine services.  
 
The bone scan you received is considered a nuclear medicine service. You have been asked to pay a $350 
copayment for a bone scan. A bone scan falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 reduce the copayment for a bone scan provided on 
December 6, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Orthovisc (J7324). 
 
You asked the Plan to pre-approve Orthovisc. You say that the requested treatment is a necessity for your care. 
The Plan denied your request. The Plan says medical necessity rules for the requested drug have not been met. 
 
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 Orthovisc. Our reviewer says that the 
requested treatment is not medically reasonable and necessary in this case. Our physician reviewer found that 
you have failed previous viscosupplementation injections and are having surgery. The record does not indicate 
that injections are planned. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Orthovisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Orthovisc (J7324).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. You say that the enrollee needs this drug based upon physical 
examination. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, 
because Euflexxa is only approved for osteoarthritis of the knee which the enrollee does not have. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Euflexxa. Our reviewer says that the 
enrollee does not meet the Medicare criteria for Euflexxa. Our physician reviewer found the clinical value and 
effectiveness of Euflexxa in the setting of lumbar facet syndrome have not been demonstrated in peer-reviewed 
literature. This is not Food & Drug Administration (FDA) approved for the enrollee's diagnosis. Its use is not 
supported by one of the major drug compendia or by clinical research appearing in a Medicare-approved 
medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of Euflexxa.
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 admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
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 that the enrollee continues to receive acute care services, and these have not been 
denied. The medical record does not indicate that the enrollee requires services that he is not currently 
receiving but that would be available at the LTACH facility. 
 
   
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF 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 in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. 
 Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require 
an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do 
not require treatment by multiple therapies, including either physical therapy or occupational therapy, at an 
intensive rehabilitation therapy program. There is not a reasonable expectation that you 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on December 
25, 2021. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you were told there would be 
no charge because it was a federal emergency management agency (FEMA) ambulance. 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $240 
copayment for each separate ambulance service.  
 
You have been asked to pay a $240 copayment for ambulance services. Ambulance services fall within the 
Ambulance Service 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 ambulance services 
provided on December 25, 2021.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to waive the cost share for home health therapy provided from April 29, 2021, to 
May 27, 2021. 
 
You asked the Plan to waive the cost share for home health therapy. You say that you would not have taken the 
therapy if you would have known you would be charged for their services. You also said you thought your 
insurance would pay for it. The Plan denied your request. The Plan says that 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 enrollees must pay a $0 copayment for an in-network home health visit. Your 
contract with the Plan does not state that you have a deductible. 
 
The Plan says you must pay $484.19 that was applied to your deductible for home health therapy. Based on the 
Plan contract, however, you cannot be asked to pay more than a $0 copayment for home health therapy. 
Therefore, we decided that the Plan has to waive the cost share for home health therapy provided from April 
29, 2021, to May 27, 2021.  
 
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 waive the copayment for a gynecology specialist office visit 
provided on August 24, 2021. 
 
You asked the Plan to waive the copayment for a gynecology specialist office visit. You say that due to a 
hardship you would like to be reimbursed. 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 
copayment for an in-network specialist office visit.  
 
You have been asked to pay a $45 copayment for a gynecology specialist office visit. A gynecology specialist 
office 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 gynecology specialist office visit provided on August 24, 
2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided on 
November 4, 2021. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that the nurse on-site said 
there would not be a charge. You also say you waited for over three hours to be seen. 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $120 
copayment for each emergency room visit.  
 
You have been asked to pay a $120 copayment for an emergency room visit. An emergency room visit falls 
within the Emergency 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 an emergency room visit provided on November 4, 2021.  
 
Your complaint about your long wait time at the emergency room 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 pay for chiropractic services provided from September 27, 2021, to 
October 15, 2021. 
 
You asked the Plan to pay for these services. You say that your copayment should only be $5. The Plan denied 
your request. The Plan says they will only cover those services related to only manual manipulation of the 
spine. Physical therapy is not covered when performed by a chiropractor 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. The records show the services denied were not 
manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for chiropractic 
services provided from September 27, 2021, to October 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two fixed bridges comprised of porcelain and base 
metal pontics (D6241) and retainer crowns (D6751) for teeth #4-#6 and #11-#14. 
 
You asked the Plan to pre-approve fixed bridgework. You say that fixed bridges are the best option for the 
enrollee, as his gag reflex will not tolerate a removable prosthetic. Anxiety of gagging will lead to poor hygiene 
and many complications. The Plan denied your request. The Plan says the narrative fails to indicate or support 
that the enrollee has any specific physical or psychological condition(s) that preclude the use of a removable 
prosthesis. A gag reflex is not an absolute contraindication for removable prostheses. Dentures can usually be 
modified or adjusted so they can be tolerated and worn. 
 
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. The Plan covers fixed 
bridgework when the services are medically necessary and reasonable. The Plan also provides that the 
placement of a fixed prosthetic appliance will only be considered for those exceptional cases where there is a 
documented physical or neurological disorder that would preclude placement of a removable prosthesis. 
 
 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 fixed bridgework. Our reviewer says 
that the Plans criteria for fixed dental bridgework are not met in this case. Our physician reviewer found that 
this request is for two fixed bridges on the upper arch which would be replacing tooth #5 on the upper right and 
tooth #12 on the upper left. The enrollee is claiming a gag reflex that would preclude the use of a removable 
prosthesis, however in most instances a removable appliance can be designed or adjusted such this would not 
be a chronic problem. The current record does not indicate any disorder that would make a removable 
appliance unwearable. Given that, a removable appliance would be a viable option and could be designed as to 
limit a gag reflex given the position of the missing teeth. Although a fixed bridge is a viable option on the 
upper left and upper right, it is one of several treatment plans available in this case.  As the Plan criteria for 
coverage has not been met (i.e., a showing of a disorder precluding use of a removable appliance), there would 
be no necessity for the requested treatment under the Plan. 
 
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 fixed bridgework have not been met. Therefore, we decided that the Plan does 
not have to pre-approve two fixed bridges comprised of porcelain and base metal pontics (D6241) and retainer 
crowns (D6751) for teeth #4-#6 and #11-#14.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided on August 26, 2021. 
 
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The 
Plan denied your request. The Plan says the services billed by the provider are not covered. In addition, the 
Plan reviewed the claim history for all chiropractic services provided previously. There are no claims submitted 
with the code 98941 from this provider or any other providers. Therefore, there is no evidence the Plan paid for 
this service in the past. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not 
manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for chiropractic 
services provided on August 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
October 22, 2021, to October 25, 2021. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that there was an error made 
during your colonoscopy which caused you to be admitted to the hospital. You also say you filed a complaint 
with the Quality Improvement Organization about your treatment. 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $360 
copayment per day for days 1-5 for inpatient hospital care.   
 Maximus cannot address quality of care issues. We can only review whether the Plan charged you the correct 
cost sharing amount based on Medicare rules and your Evidence of Coverage. You have been asked to pay a 
total of $1,080 for an inpatient hospital stay ($360 per day x 3 days = $1,080 copayment). There is no charge 
for the day of discharge. An inpatient hospital stay 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 an inpatient hospital stay provided from October 22, 2021, 
to October 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a telephone home alert system. 
 
You asked the Plan to pre-approve a telephone home alert system. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says a telephone home alert system is not 
covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that alert systems are emergency communications 
systems and do not serve a diagnostic or therapeutic purpose. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an alert device system has not been met. Therefore, we decided that the Plan does not have to pre-
approve a telephone home alert system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of implant body: endosteal implant 
(CPT code D6010) and bone graft at time of implant placement (CPT code D6104). 
 
You asked the Plan to pre-approve the dental services. You say that you cannot chew food without this implant. 
The Plan denied your request. The Plan says based on your records your dentist sent in, they did not tell the 
Plan about the plan for all teeth. The Plan states that without this plan being given to the health plan the long-
term outlook of your oral health is not established as having a good outlook with this service. 
 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. The Plan covers the dental 
services 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 dental services. Our physician 
reviewer found the documentation provided was incomplete. Consideration of the condition of your total oral 
health must be included to determine the prognosis of the proposed treatment. 
 
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 dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve surgical placement of implant body: endosteal implant (CPT code D6010) and bone 
graft at time of implant placement (CPT code D6104).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that your provider believes this will work better for you. 
The Plan denied your request. The Plan says step therapy requirements have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Prolia. Our reviewer says that the 
requirements for Prolia have not been met. Our physician reviewer found the Plan requires a trial of Fosamax 
and Actonel before they will approve the requested drug. The provided records do not indicate that you have 
tried and failed the required drugs. The records do not indicate that these drugs would likely be less effective or 
have adverse effects. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.