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

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided to the 
enrollee on May 14, 2022. 
 
You asked the Plan to waive the copayment for the specialist visit. You say that the enrollee was only seen for 
a COVID-19 test. The Plan denied your request. The Plan says the enrollee has 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $35 copayment for each specialist visit.  
 
The enrollee has been asked to pay $24.47, which is less than the $35 copayment for the specialist visit. The 
specialist visit falls within the Physician/Practitioner Services, Including Doctor's Office Visits benefit 
category. This means that the enrollee has been asked to pay the correct amount based on the contract with the 
Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a specialist office visit provided 
to the enrollee on May 14, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a second ambulance transportation 
provided on March 31, 2022. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that the hospital did not 
offer the service you needed. You say that you had to be transferred to another hospital. 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 $300 
copayment for each one-way ground ambulance transportation.  
 
You have been asked to pay a $300 copayment for the ambulance transportation. The ambulance transportation 
falls 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 a 
second ambulance transportation provided on March 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary visit provided on October 7, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the domiciliary visit. You say that the provider depends on the hospital staff to 
verify eligibility and to obtain the proper authorization from the enrollee's insurance company. The Plan denied 
your request. The Plan says no prior authorization was obtained. 
 
 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 
domiciliary visit. We found no exception that would require the Plan to pay for the domiciliary visit. The 
records provided for review do not show that the domiciliary visit was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for the domiciliary visit provided on October 7, 2021, by an out-of-
network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oncology services (81551) provided on January 20, 2022 by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the oncology services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they were 
non-emergent and prior authorization was not obtained. 
 
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 oncology services (81551) provided on January 
20, 2022 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and related services provided on April 21, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit and the related services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says no prior authorization was obtained. 
 
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 
office visit and the related services. We found no exception that would require the Plan to pay for the office 
visit and the related services. The records provided for review do not show that the services at issue were 
urgent or emergent. Therefore, we decided that the Plan does not have to pay for the office visit and related 
services provided on April 21, 2022, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer. 
 
You asked the Plan to pre-approve Injectafer. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
 
 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 Injectafer. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has iron deficiency anemia. The documentation does not support that the enrollee has tried 
and failed Infed (iron dextran) and Venofer (iron sucrose). the documentation does not support that Infed (iron 
dextran) and Venofer would likely be less effective and/or likely have adverse effects for the enrollee. 
Therefore, the enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for clinic services (87804, 99283, 87426) provided December 
27, 2021. 
 
You asked the Plan to pay for the clinic services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says this provider is not eligible to receive Medicare payment. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for clinic services (87804, 99283, 87426) 
provided December 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrocardiogram report provided on May 10, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the electrocardiogram report. You say that the service was medically necessary. 
 The Plan denied your request. The Plan says no prior authorization was obtained. 
 
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 
electrocardiogram report. We found no exception that would require the Plan to pay for the electrocardiogram 
report. Therefore, we decided that the Plan does not have to pay for the electrocardiogram report provided on 
May 10, 2022, by an out-of-network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer. 
 
You asked the Plan to pre-approve Injectafer. You say that the requested Injectafer is medically necessary. The 
Plan denied your request. The Plan says the enrollee must try and fail Ferrlecti, Infed, and Venofer first. 
 
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 Injectafer. Our reviewer says that the 
Plan's step therapy criteria have not been met. Our physician reviewer found the Plan requires a trial of 
Ferrlecti, Infed, and Venofer first before they will approve the requested drug. In this case, the enrollee has not 
tried and failed the required drug(s). There is no documentation provided indicating that the plans required 
drug(s) would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you are currently getting physical therapy at home 
two times a week but your home does not have the equipment necessary to do thorough physical therapy. The 
Plan denied your request. The Plan says there is no documentation that shows you have a medical problem that 
needs special daily care that only a skilled person can do. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do not have documented skilled nursing or skilled therapy needs. Our 
physician reviewer also found that daily skilled services are not shown to be required to establish a 
maintenance program or to prevent deterioration of your condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device 
(HFCWOD). 
 
You asked the Plan to pre-approve a HFCWOD. You say that the device is medically necessary. The Plan 
denied your request. The Plan says the requested device is not medically necessary as it does not meet the LCD 
requirements for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.  
 
 
 
 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 a HFCWOD. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the enrollee has COPD, but does not have 
bronchiectasis, cystic fibrosis, or neuromuscular disease. HFCWO has not been convincingly shown to be 
beneficial in the treatment of COPD, and Medicare does not cover it for that diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a HFCWOD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a high frequency chest wall oscillation device (HFCWOD).
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to provide coverage for a continuous glucose monitor (CGM) and supplies for use with an insulin pump for the enrollee.
You asked the Plan to provide coverage for this device. You say that this device is medically necessary. The Plan denied your request. The Plan says that Medicare coverage criteria were not met. Maximus overturned the Plans denial. After the decision was made, Maximus was given new direction by Medicare regarding coverage criteria for these units.
Our Medical Director looked at the case file and the information provided by Medicare. At issue is coverage for a continuous glucose monitor (CGM). In this case, the pump is a Medtronic system coded A9276. The medical records show the enrollee is a 65-year-old man with a diagnosis of Type 2 diabetes mellitus with hyperglycemia. Frequent episodes of hypoglycemia are reported. The enrollee has been on insulin for 25 years and started an insulin pump 9 years ago. The Endocrinology note dated February 23, 2022, documents that the enrollee was educated not to touch the insulin pump settings and to only use the bolus wizard for dosing with meals and to let the pump do its job. The enrollee was to check sugars 4 times per day, improve diet control, and increase exercise as tolerated. The documentation supports that the enrollee has diabetes and has been using an insulin pump for many years. The documentation supports that the CGM is medically reasonable and necessary for the enrollee in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this device have been met. Therefore, we decided that the Plan has to provide coverage for a continuous glucose monitor (CGM) and supplies for use with an insulin pump for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and annual wellness visit provided on March 
24, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit and annual wellness visit. You say that you resubmitted the claim 
as practice and would like a reconsideration of payment. The Plan denied your request. The Plan says no prior 
authorization was obtained. 
 
 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 
office visit and annual wellness visit. We found no exception that would require the Plan to pay for the office 
visit and annual wellness visit. The records provided for review do not show that the services at issue were 
urgent or emergent. Therefore, we decided that the Plan does not have to pay for the office visit and annual 
wellness visit provided on March 24, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex device. 
 
You asked the Plan to pre-approve a Vertiflex device. You say that the requested Vertiflex device is medically 
necessary. The Plan denied your request. The Plan says the requested Vertiflex device is 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 a Vertiflex device. Our reviewer says 
that the requested Vertiflex device is not medically necessary. Our physician reviewer found the enrollee was 
being treated for spinal stenosis of the lumbar region, with neurogenic claudication. He presented with low 
back pain with right lumbar radicular symptoms radiating down the lateral and anterolateral aspect of the thigh. 
The pain continues towards the ankle. He notes the radicular pain has intensified. 
 
However, current evidence based medical guideline and peer reviewed literature do not fully support the spinal 
decompression device procedure over the gold standard of lumbar laminectomy. There is a lack of large 
volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollees medical condition as discussed above. There is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. Therefore, the request for Vertiflex Superion 
interspinous device at L4-5 is 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 a Vertiflex device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Vertiflex device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0656, 
E0669). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that the requested items are 
medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met. The 
enrollee must have edema extending into the chest, trunk, and/or abdomen and she must have failed a four-
week trial of a basic compression pump. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652, E0656, E0669).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for refractions and an Optometry visit (99214, 92015) provided 
May 31, 2022. 
 
You asked the Plan to pay for the refractions and an Optometry visit. You say that the service should be fully 
covered. The Plan denied your request. The Plan says the correct cost-sharing was applied. 
 
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 specialist visits.  
 
You have been asked to pay a $35 copayment for an Optometry visit. The Optometry visit falls within the 
specialist 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. The refractions performed were not part of a routine annual eye exam, and therefore are not covered 
under the benefit. Therefore, we decided that the Plan does not have to pay for refractions and an Optometry 
visit (99214, 92015) provided May 31, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the thorax (71250, 
71260, 71270). 
 
You asked the Plan to pre-approve a CT scan of the thorax. You say that the CT scan is medically necessary. 
The Plan denied your request. The Plan says the enrollee is not symptomatic. The granulomas do not require 
further testing and the request is not medically reasonable or necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT 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 a CT scan of the thorax. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found the enrollee is a past smoker 
with COPD. A chest CT scan on 2/12/2019, done for lung cancer screening, describes "a few calcified 
granulomas", which are very low risk for lung cancer and do not require imaging follow-up. A recent clinical 
note describes a chest CT done in 5/2021 showing "nodular opacities", but the report is not provided, and there 
is no comparison to the 2019 scan. It is unclear whether this scan showed any new nodules, other than the 
calcified granulomas. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a CT scan of the thorax have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a computed tomography (CT) scan of the thorax (71250, 71260, 71270).