Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme. 
 
You asked the Plan to pre-approve Feraheme. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has 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 Feraheme. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found based on the medical records provided 
there is no indication that you have tried and failed the required drugs. There is no indication that the plan's 
required drugs would likely be less effective and/or likely 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 Feraheme have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Feraheme.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral radiographic images (D0230), a 2D 
photographic image (D0350), a cone beam (D0367), gingival irrigations (D4921), and unspecified periodontal 
procedure (D4999) provided on November 28, 2022, and December 9, 2022. 
 
You asked the Plan to pay for the dental services. You say that the dental procedures should be covered for a 
new patient, and you would like the Plan to reconsider the charges. The Plan denied your request. The Plan 
says your benefit for the intraoral radiographic images has already been exhausted. Also, the denial of payment 
for the 2D photographic image, cone beam, gingival irrigations, and unspecified periodontal procedure is 
correct because they are not covered by the Plan. 
 
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, certain limitations apply. The record 
shows the Plan paid for an intraoral radiographic image (D0220) on November 28, 2022; therefore, your 
benefit for the requested item or service was exhausted on the date of service of November 28, 2022. The 2D 
photographic image, cone beam, gingival irrigations, and unspecified periodontal procedure are not covered 
under the Plans dental benefit. Therefore, we decided that the Plan does not have to pay for the intraoral 
radiographic images (D0230), a 2D photographic image (D0350), a cone beam (D0367), gingival irrigations 
(D4921), and unspecified periodontal procedure (D4999) provided on November 28, 2022, and December 9, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot inserts. 
 
You asked the Plan to pre-approve foot inserts. You say that you have been using the same pair of custom 
orthotics for 6 years. You also say that this seems like a very reasonable period for replacement. The Plan 
denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot inserts.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy treatments provided on August 24, 2022. 
 
You asked the Plan to pay for physical therapy treatments. You say that you needed these services and this was 
what worked best for you. 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 physical therapy 
treatments provided on August 24, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for a tomographic myocardial perfusion 
imaging service and an injection on November 16, 2022. 
 
You asked the Plan to waive the cost share for a diagnostic radiology service and an injection. You say that you 
are experiencing financial hardship and testing was required prior to surgery. 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 $250 
copayment for Medicare-covered diagnostic radiology services that are not ultrasounds. 
 
 Your contract with the Plan also clearly says that you must pay a 20% coinsurance for Medicare Part B non-
chemotherapy prescription drugs. 
 
You have been asked to pay a $250 copayment for a diagnostic radiology service. This item/service falls within 
the Medicare-covered diagnostic radiology services that are not ultrasounds benefit category. You have also 
been asked to pay a $49.08 coinsurance for an injection ($245.40 allowed amount x 20% coinsurance = $49.08 
applied coinsurance. This item/service falls within the Medicare Part B non-chemotherapy prescription drugs 
benefit category. You have been asked to pay a total of  $299.08 cost share ($250 copayment + $49.08 
coinsurance = $299.08 cost share). 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 cost share for a tomographic 
myocardial perfusion imaging service and an injection on November 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for custom fabricated abutment  includes placement (D6057), 
and abutment supported porcelain/ceramic crown (D6058) for tooth #31 provided on November 22, 2022. 
 
You asked the Plan to pay for codes D6057 and 6058. You say that you were in pain from a broken tooth that 
became infected and inflamed. You also say that this is the final stage of the replacement claim that you are 
appealing. The Plan denied your request. The Plan says these services are not covered under the benefit 
package. 
 
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 pay for custom 
fabricated abutment  includes placement (D6057), and abutment supported porcelain/ceramic crown (D6058) 
for tooth #31 provided on November 22, 2022.
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 services are necessary as you are a fall risk and 
hope to regain maximum function and return home independently. The Plan denied your request. The Plan says 
the services you need can be provided safely in another setting. 
 
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 you do not require treatment by multiple therapies. While the medical record 
supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different level of care. 
 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a patency capsule. 
 
You asked the Plan to pre-approve the capsule. You say that this is medically necessary. The Plan denied your 
request. The Plan says the patency capsule has not been medically proven to be effective. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the capsule. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that both 2-views of the abdomen on 1/31/2023 and the computed tomography (CT) scan on 1/3/2023 
showed no obstructions, thus rendering mute the medical appropriateness nor necessity of the patency capsule 
under review.  
 
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 capsule have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a patency capsule.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a physical therapy visit provided on August 22, 2022. 
 
You asked the Plan to pay for a physical therapy visit. You say that you needed this service but it was denied. 
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 a physical therapy visit 
provided on August 22, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the electrocardiogram (EKG) provided on 
September 30, 2022. 
 
You asked the Plan to waive the copayment for the EKG. You say that this should have been a packaged 
charge. 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 $35 
copayment for Medicare-covered non-radiological diagnostic services, including EKGs.  
 
The records show that the claims were processed correctly. You have been asked to pay a $35 copayment for 
the EKG. This item/service falls within the outpatient diagnostic tests and therapeutic services benefit category. 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for the electrocardiogram (EKG) provided on September 30, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an extraction, erupted tooth or exposed root (D7140), 
and a bone replacement graft for ridge preservation - per site (D7953). 
 
You asked the Plan to pre-approve the dental services. You say that you were given a pre-authorization denial 
for a bone graft procedure. You also say that this dental practice is a contracted dentist and the service should 
be covered. The Plan denied your request. The Plan says dental services from an out-of-network provider are 
not covered by your supplemental 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. 
 
You are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested items or services are not covered under this benefit when received 
from an out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve an 
extraction, erupted tooth or exposed root (D7140), and a bone replacement graft for ridge preservation - per site 
(D7953).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic radiographic image (D0330) provided on 
November 3, 2022. 
 
You asked the Plan to pay for the dental service. You say that you did not request a scan and you were 
discussing options on getting an implant. The Plan denied your request. The Plan says your benefit for the 
requested item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service March 17, 2021. 
Therefore, we decided that the Plan does not have to pay for the panoramic radiographic image (D0330) 
provided on November 3, 2022.  
 Your complaint about experience with the provider is not a valid appeal for medical coverage. This part of your 
complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision 
about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 82043 and 82570 provided on August 11, 
2022.  

You asked the Plan to pay for procedure codes 82043 and 82570. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The tests at issue in this appeal, procedure codes 82043 and 82570, were requested solely for screening 
purposes. Medicare does not cover these tests solely for screening purposes. Therefore, we decided that the 
Plan does not have to pay for procedure codes 82043 and 82570 provided on August 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a splint (D4323). 
 
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 a 
splint (D4323).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 22, 2022. 
 
You asked the Plan to pay for an office visit. You say that the records attached support the services provided. 
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 an office visit provided 
on September 22, 2022.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa for the enrollee.
You asked the Plan to pre-approve Euflexxa. You say that you are appealing with supporting records. The Plan
denied your request. The Plan says that the provider clearly documents in the medical record prior hyaluronan
injections did not help the enrollee. Maximus overturned the Plans denial. The Plan requested a reopen and
stated that Maximus did not apply the correct criteria
Our Medical director looked at the case file and the reopen request. At issue is coverage for Euflexxa. Our
Medical Director states that the documentation does not support that Euflexxa was expected to be safe and
effective or reasonable and necessary for the enrollee in this case. Our physician reviewer found that the
enrollee's condition does not meet criteria for Euflexxa. 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 Euflexxa for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the power seat elevation (E2300) and the gel pads 
(K0108). 
 
You asked the Plan to pre-approve the power seat elevation and gel pads. The Plan denied your request. The 
Plan says that the power seat elevation and gel pads do not serve a medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The items at issue in this appeal does not serve a purpose that is primarily medical in nature. Therefore, we 
decided that the Plan does not have to pre-approve the power seat elevation (E2300) and the gel pads (K0108).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Special Supplemental Benefits for the Chronically Ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI. You say that SSBCI is medically necessary. The Plan denied your 
request. The Plan says there is no documentation that the member meets all 3 criteria. Multiple attempts were 
made to obtain medical records, but additional supporting documentation was not obtained. 
 
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 beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
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 SSBCI have been met. No medical 
records were provided. Therefore, we decided that the Plan does not have to pre-approve Special Supplemental 
Benefits for the Chronically Ill (SSBCI).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair, single power option,
sling/solid seat/back, patient weight capacity up to and including 300 pounds (K0856) expandable controller
(E2377) harness (E2313) electronic connection (E2311) and replacement joystick (E2374).
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The
Plan denied your request. The Plan says that the enrollee does not have a medical need for the requested group
3 power wheelchair.
Our Medical director looked at the case file and the reopen request. At issue is coverage for a group 3 power
wheelchair, single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds
(K0856) expandable controller (E2377) harness (E2313) electronic connection (E2311) and replacement
joystick (E2374. Our Medical Director states that the documentation does not support that the enrollee requires
a drive control interface other than a hand or chin-operated proportional joystick, or that she meets coverage
criteria for a power tilt or power recline seating system. It is not documented that the enrollee is at high risk for
pressure ulcer. Coverage criteria for a group 3 power wheelchair (K0856) with features are not met in this case.
Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a group 3 power wheelchair, single power option, sling/solid seat/back, patient weight
capacity up to and including 300 pounds (K0856) expandable controller (E2377) harness (E2313) electronic
connection (E2311) and replacement joystick (E2374).