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

 
We decided that the Plan has to waive the coinsurance for the aflibercept injection provided on September 30, 
2021. 
 
You asked the Plan to waive the coinsurance for the aflibercept injection. You say that you were informed that 
the injection would incur a $0.00 copay. The Plan denied your request. The Plan says that the coinsurance 
amount applied is correct. 
 
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 made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Since they did not give us information showing the payment of this claim, they 
have not shown that $366.56 is a correct coinsurance charge. We also find that the Plan did not show that a 
Medicare Part B prescription drug was billed on this claim. Therefore, we decided that the Plan has to waive 
the coinsurance for the aflibercept injection provided on September 30, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency services provided from November 22, 2021, to November 24, 2021.
You asked the Plan to waive the copayment for the emergency services. You say that the enrollee went to the emergency room because she thought she was having a heart attack or stroke. The Plan denied your request. The Plan says the copayment applied is correct.
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 enrollee's contract with the Plan clearly says that enrollees must pay a $120 copayment for emergency care.
The enrollee has been asked to pay a $120 copayment for the emergency services. The emergency services fall within the Emergency care 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 emergency services provided from November 22, 2021, to November 24, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MAKOplasty and hospital inpatient admission. 
 
You asked the Plan to pre-approve MAKOplasty and hospital inpatient admission. You say that the services are 
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 
coverage criteria have not been met. 
 
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 MAKOplasty and hospital inpatient 
admission. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found current evidence based medical literature does not support 
the routine use of computer-assisted navigated total knee arthroplasty over conventional total knee arthroplasty. 
Ultimate improved outcomes regarding functionality and pain relief have not been documented in large volume 
long term studies. Therefore, the request for inpatient surgery MAKOplasty 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 MAKOplasty and hospital inpatient admission have not been met. Therefore, 
we decided that the Plan does not have to pre-approve MAKOplasty and hospital inpatient admission.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the copayment for doctors office visits provided on June 4, 2021 and 
June 16, 2021. 
 
You asked the Plan to waive the copayment for the office visits. You say that you made an appointment to see 
your PCP, you were seen by a different doctor in the office and have never been charged in the past. The Plan 
denied your request. The Plan says that the copayment charged was correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay a $0 copayment for each PCP visit or telehealth service for 
Medicare-covered services. 
 
The Plan says you must pay a $30 copayment for each office visit, totaling $60. Based on the Plan contract, 
however, you cannot be asked to pay more than a $0 copayment for each PCP visit or telehealth service for 
Medicare-covered services. Therefore, we decided that the Plan has to waive the copayment for doctors office 
visits provided on June 4, 2021 and June 16, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for out-of-network emergency ground 
ambulance services provided on July 1, 2021. 
 
You asked the Plan to waive the copayment for ambulance services. You say that someone with the EMS told 
you there would be no charge. The Plan denied your request. The Plan says the copayment charged is correct. 
 
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 $290 
copayment for out-of-network emergency ground ambulance services.  
 
 
 You have been asked to pay $290 for ambulance services. Out-of-network emergency ground ambulance 
services fall 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 out-of-network emergency ground ambulance services provided on July 1, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Stelara. 
 
You asked the Plan to pre-approve Stelara. You say that the requested drug is a medical necessity for you. The 
Plan denied your request. The Plan says rules for coverage for self-administered drugs have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Stelara.  
 
Benefits for Stelara may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH). 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says care can be provided in the current inpatient hospital. 
 
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 improving and should only require short-term additional 
acute care services that can safely be administered at the current facility. The enrollee does not require services 
at the LTACH that are not already available at the current facility. Transfer to LTACH is not medically 
necessary as it would not be clinically advantageous. Transfer to a lower level of care 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 admission to a long term acute care hospital (LTACH).
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 
November 15, 2021. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that the copayment should be 
waived because the office visit was a follow up. The Plan denied your request. The Plan says the copayment 
charged is correct. 
 
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 a specialist office visit.  
 
  
A follow up visit copayment of $0 only applies when you are discharged from a hospital, SNF, Community 
Mental Health Centers stay, outpatient observation, or partial hospitalization that meets the requirements as 
defined by Medicare. 
 
You have been asked to pay $40 for a specialist office visit. Specialist office visits fall 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 November 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for optometry services (92002) provided on August 30, 2021. 
 
You asked the Plan to pay for the optometry services. You say that the services were medically necessary and 
should be covered. The Plan denied your request. The Plan says the out-of-network services were not emergent 
or pre-authorized. 
 
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 services at issue in this appeal. The Plan did not pre-approve the service 
at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided 
that the Plan does not have to pay for optometry services (92002) provided on August 30, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (70450) provided October 26, 2021. 
 You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the code billed shares a bundled relationship with another code billed 
and is not separately payable. 
 
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, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for radiology services (70450) provided October 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay from October 30, 
2021, to October 31, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you do not feel you 
should be liable because you were your primary caregiver during your stay. The Plan denied your request. The 
Plan says the copayment applied was correct. 
 
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 day in a hospital for the first five days.  
 
 
 You have been asked to pay a $300 copayment for the inpatient hospital stay. The inpatient hospital stay falls 
within the Inpatient hospital care benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
the inpatient hospital stay from October 30, 2021, to October 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided the Plan does not have to pay for dental services provided from March 29, 2021, to April 12, 2021.
You asked the Plan to pay for these dental services. You say that these services should be covered by the Plan.
The Plan denied your request. The Plan says these services were exhausted prior to being rendered. Maximus
partially overturned the Plans denial. The Plan requested a reopen and provided additional information. The
Plan says that the benefits for this service had been satisfied and the frequency limitation has been exceeded.
The Plan contract says comprehensive oral evaluation and periodontal exams are allowed once in every three
years and x-rays are allowed once per calendar year. The case file includes the appealed claim and the referring
claim that shows you exhausted these benefits on January 22, 2018, and February 18, 2020.
The Plan is correct in the case. Medicare generally 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.
Though the Plan offers a dental benefit more than Medicare coverage, the benefits for the services provided
were exhausted prior to the dates of service in question. Therefore, we decided that the Plan does not have to
pay for dental services provided from March 29, 2021, to April 12, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ultrasound (76700) provided on 
October 27, 2021 
 
You asked the Plan to waive the copayment for the ultrasound. You say that there should be a zero copayment. 
The Plan denied your request. The Plan says the copayment amount charged is correct. 
 
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 $125 
copayment for Medicare-covered radiological diagnostic services, not including X-rays, performed in a 
physicians office or at a free-standing facility (such as a radiology center or medical clinic). The diagnostic 
radiology services require specialized equipment beyond standard X-ray equipment and must be performed by 
specially trained or certified personnel. Examples include, but are not limited to, specialized scans, CT, 
SPECT, PET, MRI, MRA, nuclear studies, ultrasounds, diagnostic mammograms and interventional 
radiological procedures (myelogram, cystogram, angiogram, and barium studies). 
 You have been asked to pay $125 for the ultrasound. Ultrasounds fall within the Outpatient Diagnostic Tests 
and Therapeutic Services and Supplies benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for the ultrasound (76700) provided on October 27, 2021
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to waive the copayment for the CPAP machine provided from September 9, 2021, 
to November 9, 2021. 
 
You asked the Plan to waive the copayment for the CPAP machine. You say that they are trying to sell a 
product that has never been delivered to you because you told them you do not want their product. The Plan 
denied your request. The Plan says that the coinsurance applied is correct. 
 
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 made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has not provided proof of this equipment being delivered. Therefore, 
we decided that the Plan has to waive the copayment for the CPAP machine provided from September 9, 2021, 
to November 9, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to waive the copayment for physician services provided from November 10, 
2021, to November 11, 2021. 
 
You asked the Plan to waive the copayment for physician services. You say that you already paid the $90 
copay for the emergency room and should not have to pay an additional copay for the provider. The Plan 
denied your request. The Plan says that the copayment applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information. Your 
contract with the Plan says that enrollees must pay a $90 copay for Medicare-covered emergency room visits 
for Emergency care.  
 
The Plan says you must pay $60 copay for physician services, in addition to the $90 emergency care 
copayment. Based on the Plan contract, however, you cannot be asked to pay more than a $90 copay for 
Medicare-covered emergency room visits for physician services, which you have already been asked to pay. 
Therefore, we decided that the Plan has to waive the copayment for physician services provided from 
November 10, 2021, to November 11, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve an L4 transforaminal epidural injection (TFESI). 
 
You asked the Plan to pre-approve an L4 transforaminal epidural injection. You say that the services are 
necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage 
criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that epidural steroid injections are covered when specific 
criteria are met. 
 
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 L4 transforaminal epidural injection. 
Our reviewer says that the service is medically necessary. Our physician reviewer found the physician 
withdrew the request for 2 levels of TFESI. The L4 TFESI is medically reasonable and 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 an L4 transforaminal epidural injection have been met. Therefore, we decided 
that the Plan has to pre-approve an L4 transforaminal epidural injection (TFESI).  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 1 heavy duty power operated vehicle (K0801). 
 
You asked the Plan to pre-approve a heavy duty power operated vehicle. You say that the requested item is a 
medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for the 
requested item have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that a POV is covered when the enrollee's weight is 
less than or equal to the weight capacity of the POV that is provided and greater than or equal to 95% of the 
weight capacity of the next lower weight class POV. A Heavy Duty POV is covered for an enrollee weighing 
285  450 pounds. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a heavy duty power operated vehicle have not been met. Specifically, the provided medical records 
indicate that the enrollee's weight is fewer than 285 pounds. Therefore, we decided that the Plan does not have 
to pre-approve a Group 1 heavy duty power operated vehicle (K0801).