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

 
We decided that the Plan does not have to waive the deductible for a tangential skin biopsy provided on 
January 4, 2022. 
 
You asked the Plan to waive the deductible for a skin biopsy. You say that it is unclear why every time you go 
to the dermatologist now there is going to be an extra charge. You also say this service is part of cancer 
prevention and it is as important as a yearly physical. The Plan denied your request. The Plan says you have 
been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $750 deductible which applies to outpatient surgery.  
 
A tangential skin biopsy is considered a surgical procedure. The skin biopsy you asked the Plan to waive the 
deductible falls within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities 
and Ambulatory Surgical Centers benefit category. The Plan has followed Medicare rules by clearly disclosing 
in the contract that there is a $750 which applies to outpatient surgery. This cost sharing is a contractual 
obligation that had not been met at the time a skin biopsy was received on January 4, 2022. Therefore, we 
decided that the Plan does not have to waive the deductible for a tangential skin biopsy provided on January 4, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the nuclear stress test and the Part B drug 
provided by a network physician on September 23, 2021. 
 
You asked the Plan to waive the cost share for the nuclear stress test and the Part B drug. You say that every 
other service on this date of service was fully covered. You say Medicare should cover these services as well. 
The Plan denied your request. The Plan says you have been asked to pay 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 $275 
copayment per day, per provider, for in-network Medicare covered diagnostic radiology services and 20% for 
each Medicare-covered Part B drug for Part B drugs obtained in a provider's office or outpatient setting.  
 
You have been asked to pay a $275 copayment for the nuclear stress test and $47.64 which is 20% of the 
allowed amount for the Part B drug. The allowed amount is $238.20. ($238.20 x 20% = $47.64).  The nuclear 
stress test falls within the Outpatient diagnostic tests and therapeutic services and supplies benefit category. 
The Part B drug falls within the Medicare Part B prescription drugs 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 cost share for the nuclear stress test and the Part B drug provided by a network 
physician on September 23, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Gel-One (J7326). 
 
You asked the Plan to pre-approve Gel-One. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says step therapy rules for the requested drug 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 Gel-One. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
Plan requires a trial of drugs Synvisc, Durolane, and Gelsyn-3 before they will approve the requested drug. The 
case file does not contain documentation of trial and failure of the Plan's required drugs. The documentation 
does not support that the plan's required drugs would likely be less effective and/or would likely have adverse 
effects 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 Gel-One have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Gel-One (J7326).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on January 
12, 2022. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that you only saw the 
physician assistant and would like the copayment waived. The Plan denied your request. The Plan says the 
provider billed appropriately, and the proper copayment 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 $40 
copayment for services obtained from a specialist, or under certain circumstances, treatment by a nurse 
practitioner or physicians assistant or other non-physician health care professionals in a specialists office.  You have been asked to pay a $40 copayment for the specialist office visit. The specialist office visit falls 
within the Physician/Practitioner Services, Including Doctors 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 specialist office visit provided on January 12, 2022.
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 requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 the enrollee appears to be more stable and improving and should only require short-
term additional acute care services that can safely be administered at the current facility until more appropriate 
for transfer to a lower level of care. There are no services at the LTACH that the enrollee requires that are not 
already available at the current facility. Transfer may be considered when treatment has completed. 
 
 
 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye exam and refraction you received from an out-of-
network vision provider on October 19, 2020. 
 You asked the Plan to pay for the out-of-network vision services. You say that you believe that you filed this 
claim timely so it should be considered. The Plan denied your request. The Plan says there is no coverage for 
vision services you receive from an out-of-network provider. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers routine vision services only when you use the Plan's network vision provider.  The 
provider you saw on the date of service in question is not the Plan's network vision provider. Based on this 
information, we decided that the Plan's rules for coverage of the out-of-network vision services have not been 
met. Therefore, we decided that the Plan does not have to pay for the eye exam and refraction you received 
from an out-of-network vision provider on October 19, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care services provided to the enrollee on October 1, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says CPT 99291 is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99291 is "Critical care, evaluation and management of 
the critically ill or critically injured patient; first 30-74 minutes." 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, there was no documentation 
showing the time spent providing the critical care services. This documentation is necessary as CPT 99291 is a 
time-based code. Based on this information, we decided that Medicare rules for coverage of the services have 
not been met. Therefore, we decided that the Plan does not have to pay for critical care services provided to the 
enrollee on October 1, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided to the enrollee on October 31, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says there is no evidence that this was either emergent or medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 pay for the services. Our reviewer says that the 
services at issue in this case were not medically reasonable or necessary. Our physician reviewer found the 
review has determined that the documentation does not support that other means of transport (such as stretcher 
van, wheelchair van, taxi, private car, or other type of vehicle) were contraindicated for this patient on October 
31,2021. The documentation does not support that the patient needed the expertise, services and lifesaving and 
life-sustaining equipment that only a fully-equipped ambulance can provide for safe transport on October 
31,2021. The documentation  does not support that the ambulance transport on October 31,2021 was medically 
reasonable and necessary for the patient. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for ambulance services provided to the enrollee on October 31, 2021.
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 requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 the enrollee appears to be more stable and improving close to baseline function and 
should only require short-term additional acute care services including additional oxygen weaning that can 
safely be administered at the current facility until more appropriate for transfer to a lower level of care. There 
are no services at the LTACH that the enrollee requires that are not already available at the current facility.  
Transfer may be considered when treatment has completed. 
 
 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care services provided on September 22, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the wound care services. You say that these services were medically necessary 
and should be covered. The Plan denied your request. The Plan says unauthorized, non-plan 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. 
 Your organization 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 wound care 
services 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 wound care services provided on September 22, 2021, by an 
out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room (ER) services provided on 
January 18, 2022. 
 
You asked the Plan to waive the copayment for emergency room services. You say that you called the Plan and 
were told it would be cheaper to go to the emergency room (ER) as far as the copayment goes to get a magnetic 
resonance imaging (MRI), so you went to this facility on January 18, 2022, to get an MRI. You also say that 
they said the emergency room staff said you did not qualify for an MRI in the ER, and they gave you two 
Tylenol and sent you home. You also say you are mad about this facility not doing more and feel that you 
should not have to pay that copayment. The Plan denied your request. The Plan says you were 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 $90 
copayment for each emergency care visit.  
 
 You have been asked to pay a $90 copayment for emergency room services. Emergency room services fall 
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 emergency 
room (ER) services provided on January 18, 2022.  
 
Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus 
Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the 
appropriate Quality Improvement Organization for further review. 
 
Your complaint about the potentially poor service from the emergency room facility 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for wound debridement procedures performed 
from August 3, 2021, to August 17, 2021. 
 
You asked the Plan to waive the copayment for the wound debridement. You say that you did not have surgery. 
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 $250 
copayment for each outpatient surgery.  
 
The file shows that you had two separate wound debridement procedures performed from August 3, 2021, to 
August 17, 2021. The file also shows that only one copayment was applied for both visits. Therefore, you have 
been asked to pay a $250 copayment for the wound debridement. The wound debridement falls within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical 
Centers benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for wound debridement 
procedures performed from August 3, 2021, to August 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lightweight wheelchair (K0003), elevating leg rest (K0195) 
and cushions (E2601 and E2611). 
 
You asked the Plan to pay for the lightweight wheelchair, elevating leg rests and cushions. You say that you 
would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the 
enrollee does not meet criteria for the requested wheelchair. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of a lightweight wheelchair (K0003), 
elevating leg rest (K0195) and cushions (E2601 and E2611). have been met. Specifically, the documentation 
does not include sufficient clinical information to determine if the enrollee cannot self-propel in a standard 
wheelchair in the home and can and does self-propel in a lightweight wheelchair. The documentation does not 
show that the beneficiarys mobility limitation cannot be sufficiently resolved by the use of an appropriately 
fitted cane or walker or that the beneficiarys home provides adequate access between rooms, maneuvering 
space, and surfaces for use of the manual wheelchair that is provided. 
. Therefore, we decided that the Plan does not have to pay for a lightweight wheelchair (K0003), elevating leg 
rest (K0195) and cushions (E2601 and E2611).
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 requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 you appear to be more stable and improving and should only require short-term 
additional acute care services that can safely be administered at the current facility until more appropriate for 
transfer to a lower level of care. There are no services at the LTACH that you require that are not already 
available at the current facility. Transfer may be considered when treatment has completed. 
 
 
 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lumigan Solution. 
 
You asked the Plan to pre-approve the Lumigan Solution. You say that you would like reconsideration because 
the requested eye drops are medically necessary. The Plan denied your request. The Plan says this drug is not 
covered under Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Lumigan Solution.  
 Benefits for the Lumigan Solution may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.