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

 
We decided that the Plan does not have to pre-approve Rituxan (J9312) and Revlimid (J8999). 
 
  You asked the Plan to pre-approve Rituxan and Revlimid. You say that Rituxan will be given as a standard of 
care during a clinical trial. You also say that the study will not cover this medication, as this medication will be 
buy/billed to the medical plan. The Plan denied your request. The Plan says according to the medical records 
provided, the enrollee is enrolled in a clinical trial. The Plan also says that coverage of the requested drug 
would be deemed a routine cost covered by the Medicare Administrative Contractor (MAC). 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve Rituxan and Revlimid as part of a clinical trial. The Plan does 
not cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not 
have to pre-approve Rituxan (J9312) and Revlimid (J8999).
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve capsulotomy to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve capsulotomy. You say that you are requesting reconsideration. The Plan 
denied your request. The Plan says the enrollee must receive their care from a network provider (for more 
information about this, see Section 2 in Chapter 3). In most cases, care the enrollee receives from an out-of-
network provider (a provider who is not part of the plans network) will not be covered. This means that the 
enrollee will have to pay the provider in full for the services furnished. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
capsulotomy to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for the supply allowance (K0553) and receiver (K0554) for a Freestyle Libre continuous glucose monitor (CGM) requested for the enrollee.
You asked the Plan to provide coverage for this equipment. You say that at the time of the appeal, this equipment was medically necessary for the enrollee. The Plan denied your request. The Plan says there were no medical records submitted to support the coverage criteria were met. Maximus overturned the Plans denial, in error, for no medical records. The Plan requested a reopen and provided additional documentation to show medical records were requested but were not provided for their review.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the enrollee's medical documentation and confirm that Medicare coverage criteria have been met. Whether or not this type of equipment is a new request or continued coverage, all criteria must be met for approval. The Plan provided documentation to show medical records were requested but were not provided. Without records to show all the required Medicare coverage criteria are met, the Plan cannot and should not approve coverage. Therefore, we decided that the Plan does not have to provide coverage for the supply allowance (K0553) and receiver (K0554) for a Freestyle Libre continuous glucose monitor (CGM) requested for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve SNF care. You say that you disagree with the denial. The Plan denied your request. The Plan says that there is a network provider available to provide the care and services you need.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal.
We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab testing (81479) provided to the enrollee on April 13, 2021.
You asked the Plan to pay for the lab testing. You say that these services were medically necessary. The Plan denied your request. The Plan says that services billed with modifier -GZ are not covered. Maximus overturned the denial because a copy of the claim was not submitted. The Plan requested a reopening and submitted the claim form. The Plan is correct in this case. Medicare rules say that claim line(s) items submitted with a GZ modifier are automatically denied.
The claim form submitted does include the GZ modifier. Based on this information, we decided that Medicare rules for coverage of the lab testing have not been met. Therefore, we decided that the Plan does not have to pay for the lab testing (81479) provided to the enrollee on April 13, 2021.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve CT scan of the chest. 
 
You asked the Plan to pre-approve chest CT scan. You say that the enrollee needs a CT scan for lung cancer 
screening. The Plan denied your request. The Plan says that the request is being denied because no information 
was received that would allow them to select the specific guideline criteria needed for review that apply to the 
enrollee's condition. 
 
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 CT scan of the chest. Our reviewer says 
that the enrollee meets criteria for this CT scan. Our physician reviewer found that while the enrollee has a 46 
pack-yar smoking history, the enrollees last CT scan on April 19, 2022, revealed new small pulmonary 
nodules compared to a prior exam. Thus, a follow-up diagnostic CT, code 71250 is the appropriate exam to 
have been ordered rather than low-dose computed tomography (LDCT). Exam should be approved as ordered. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CT scan for lung cancer screening have been met. Therefore, we decided that 
the Plan has to pre-approve CT scan of the chest.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on November 08, 2022. 
 
You asked the Plan to pay for the office visit. You say that the website shows that no authorization is required 
for this service. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the office visit provided 
on November 08, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI. 
 
You asked the Plan to pre-approve an MRI. You say the enrollee needs an updated MRI of the lumbar spine to 
look for worsening degenerative changes, spinal stenosis, disc herniation and to help exclude non-mechanical 
causes of low back pain. The Plan denied your request. The Plan says the enrollee does not meet the criteria for 
an MRI. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 an MRI. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found that there is no documentation of 
conservative measures to include a recent 6-week trial of physical therapy (PT) for back pain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an MRI.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI), of the brain 
(including brain stem); without contrast material, followed by contrast material(s) and further sequences 
(70553). 
 
You asked the Plan to pre-approve this service. You say that the requested service is medically necessary for 
the enrollee. The Plan denied your request. The Plan says the requested service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 this service. Our reviewer says that the 
requested service is not medically necessary. Our physician reviewer found that the enrollee reported chronic 
headaches and has failed multiple medications. She describes the headaches as right-sided pressure and 
numbness of the face and waxes and wanes. She also has a history of migraines, otitis, and chronic sinus 
congestion. An MRI of the brain was requested. However, the enrollee does not have signs or symptoms 
suggestive of an acute process, intracranial or neurological abnormality, or red flag diagnosis to justify 
advanced imaging. Therefore, this request will be considered not medically necessary based on the provided 
documentation. 
 
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 service have not been met.  Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI), of the 
brain (including brain stem); without contrast material, followed by contrast material(s) and further sequences 
(70553).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the podiatry specialist office visits 
provided from October 24, 2022, to November 16, 2022. 
 
You asked the Plan to waive the copayments for the specialist office visits. You say that this service was 
needed after a nail trimming mistake. The Plan denied your request. The Plan says this cost sharing was 
charged 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 $45 
copayment for each specialist office visit.  
 
You have been asked to pay a $45 copayment for each specialist office visits. You have been asked to pay a 
total of $135 ($45 copayment per visit x 3 visits = $135). These items/services fall within the 
physician/practitioner 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 copayments for 
the podiatry specialist office visits provided from October 24, 2022, to November 16, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the iron injection, and the deductible for 
the administration of the injection provided by an in-network provider on June 30, 2022, and July 7, 2022.  
 
You asked the Plan to waive the coinsurance for the iron injection, and the deductible for the administration of 
the injection. You say that you do not think you should be responsible for paying for these services. The Plan 
denied your request. The Plan says this cost sharing was charged 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 says that you must pay the full cost for 
covered services until you have paid the $1000 deductible, and the deducible applies to in and out-of-network 
outpatient hospital services. Your contract with the Plan also says that you must pay a 20% coinsurance for all 
other in-network Medicare-covered Part B drugs. 
 
You have been asked to pay a $337.65 coinsurance for the injections ($1688.25 allowed amount for 2 
injections x .20 = $337.65). These items/services fall within the Medicare Part B prescription drugs benefit 
category. You have also been asked to pay a $495.04 deductible for the administration of the injections 
($247.52 allowed amount x 2 injections = $495.04). These items/services fall within the outpatient hospital 
services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there 
is a $1000 deductible which applies to in and out-of-network outpatient hospital services. This cost sharing is a 
contractual obligation that had not been met at the time the injections and the administration of the injections 
were received on June 30, 2022, and July 7, 2022. Therefore, we decided that the Plan does not have to waive 
the coinsurance for the iron injection, and the deductible for the administration of the injection provided by an 
in-network provider on June 30, 2022, and July 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve maxillary dentures (D5110). 
 
You asked the Plan to pre-approve the dental 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 do 
not fall within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
maxillary dentures (D5110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a retainer crown - porcelain fused to high noble
metal tooth #'s 4, 6 (D6750), and pontic - porcelain fused to high noble metal tooth #5 (D6240).
You asked the Plan to provide coverage for these dental services. You say that at the time of the appeal, these
dental services were necessary. The Plan denied your request. The Plan says the requested services were not
covered based on the dental x-rays. Maximus overturned the Plans denial. The Plan requested a reopen and
stated that Maximus did not apply the correct dental coverage criteria.
The Plan is correct in this case. Medicare does not cover dental services. However, the Plan offers a dental
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plans
dental rider states the services requested are limited to areas with one missing maxillary tooth and/or two
missing adjacent mandibular teeth.
Though the Plan offers a dental benefit more than Medicare coverage, the x-rays show you are missing too
many teeth around the area the requested bridge was to be provided. Therefore, the dental coverage criteria are
not met. Therefore, we decided that the Plan does not have to provide coverage for a retainer crown - porcelain
fused to high noble metal tooth #'s 4, 6 (D6750), and pontic - porcelain fused to high noble metal tooth #5
(D6240).
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to provide coverage for a prosthetic leg with an advanced foot with ankle feature
(K3 prosthetic foot) under codes L5986, L5987 and L5984 for the enrollee.
You asked the Plan to pre-approve an advanced foot with ankle feature (K3 prosthetic foot). You say that this
prosthetic equipment is medically necessary for the enrollee. The Plan denied your request. The Plan says that
Medicare coverage criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen
stating that Maximus neglected to review all the codes in the file. The Plan was correct that code L5986 was
omitted from the first review by Maximus. The case was sent to medical review a second time.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for a prosthetic leg
with an advanced foot with ankle feature (K3 prosthetic foot). The Maximus Physician Reviewer determined
that the enrollee's K2 prosthetic components on the preparatory prosthesis did not match the enrollee's
functional level, which was K3. The enrollee was then ambulating for long distances and on uneven terrain
with his prosthesis with and without an assistive device per the clinical progress note. The case has been
reopened because the Plan states the records do not show the enrollee is a K3 ambulator. The Plan notes that
the enrollee has multiple comorbidities, lives in a long-term care facility, and uses a walker for ambulation,
indicating that he is not a K3 ambulator. The medical records show the enrollee is a 76-year-old man who
underwent a left transtibial amputation on July 15, 2021. The progress notes dated January 13, 2023,
documents that on December 14, 2022, the enrollee was a K3 ambulator and was able to ambulate at variable
speeds over varied uneven surfaces. The enrollee reported walking multiple miles per day without an assistive
device. On January 13, 2023, it is noted that the enrollee continued to be able to ambulate over a mile with and
without assist device and was then at a K3 level. Determinations of medical necessity are tailored to the
individual patient and their unique clinical scenario. Per LCD L33787, an axial rotation unit, such as L5984
and L5986, is covered for beneficiaries whose functional level is 2 or above. Medicare coverage criteria for all
codes in question are 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 an advanced foot with ankle feature (K3 prosthetic foot) have been met.
Therefore, we decided that the Plan has to pre-approve a prosthetic leg with an advanced foot with ankle
feature (K3 prosthetic foot) under codes L5986, L5987 and L5984 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and (b). The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that enrollees must pay 20% coinsurance for Medicare Part B-covered drugs administer by a physician or staff, Medicare Part B-covered chemotherapy drugs and Medicare Part B-covered gene therapy drugs. You can see this on page 87 of the Plans 2022 Evidence of Coverage.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided the Plan has to pay for urological supplies coded as A4351-KX billed to the enrollee from April
25, 2022, to August 22, 2022.
You asked the Plan to pay this claim. You say that you have billed the enrollee several times in the same way
and there were no problems with payment. The Plan denied your request. The Plan says that this is a bundled
code and cannot be paid as billed. The Plans also ran out of time to review this case and the Plan was required
to send the case to Maximus for review. Maximus overturned the Plans denial. After the decision was made it
was determined a more detailed decision should be rendered.
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 submitted the coding regulations that support their denial. If a Plans time to review a
case expires, the Plan is still required to send a complete case file to Maximus which supports their original
denial. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding
their decision to deny your request. Therefore, we decided that the Plan has to pay for urological supplies
coded as A4351-KX billed to the enrollee from April 25, 2022, to August 22, 2022.