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

 
We decided that the Plan does not have to pre-approve Orthovisc for the right knee. 
 
You asked the Plan to pre-approve Orthovisc for the right knee. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the requested drug is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules state that knee injections are covered when there is a 
radiological exam to support the clinical diagnosis of osteoarthritis of the knee will be available in the 
enrollees medical record. 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 Orthovisc for the right knee. Our 
reviewer says that the documentation does not support that the requested drug is medically reasonable or 
necessary. Our physician reviewer found the enrollee has bilateral knee pain. Imaging studies have been 
provided confirming the diagnosis of osteoarthritis of the left knee, but no imaging studies of the right knee are 
provided. The documentation does not confirm osteoarthritis in the right knee with imaging studies. The 
documentation does not support that you have tried and failed Euflexxa. Therefore, the enrollee does not meet 
criteria for the requested right knee injections and the enrollee does not meet step therapy criteria for Orthovisc. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Orthovisc for the right knee have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Orthovisc for the right knee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided the Plan does not have to pay for a dental exam (D0150) and x-rays (D0210) provided on March 3,
2022.
You asked the Plan to pay for these dental services. You say that these dental services should be covered by the
Plan. The Plan denied your request. The Plan says your benefit for the services provided were exhausted on
March 1, 2022. Maximus overturned the Plans denial because the Plan contract and previous claim were not
included in the file. The Plan requested a reopen and provided the required documentation.
The Plan is correct in this 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.
The record shows your benefit for the exam and x-rays were exhausted March 1, 2022. Therefore, we decided
that the Plan does not have to pay for a dental exam (D0150) and x-rays (D0210) provided on March 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for the scanning computerized ophthalmic
diagnostic imaging (92134) provided on March 8, 2022.
You asked the Plan to waive the cost-sharing for the scanning computerized ophthalmic diagnostic imaging.
You say that you would like the Plan to reconsider the cost-sharing. 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 $75
copayment for diagnostic procedures and tests.
You have been asked to pay a $35.33 copayment for the scanning computerized ophthalmic diagnostic
imaging. This item/service falls within the diagnostic procedures and tests benefit category.
This means that you have been asked to pay less than the applicable 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-sharing for the scanning computerized ophthalmic
diagnostic imaging (92134) provided on March 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for the scanning computerized ophthalmic
diagnostic imaging (92133) and the outpatient office visit (99214) provided on February 2, 2022.
You asked the Plan to waive the cost-sharing for the scanning computerized ophthalmic diagnostic imaging and
the outpatient office visit. You say that you would like the cost share waived. 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 $50
copayment for diagnostic procedures and tests and a $10 copayment for office visits to specialists.
You have been asked to pay a $50 copayment for the scanning computerized ophthalmic diagnostic imaging
and a $10 copayment for the outpatient office visit. The scanning computerized ophthalmic diagnostic imaging
falls within the diagnostic procedures and tests and the outpatient office visit falls within the office visits to
specialists 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-sharing for the scanning
computerized ophthalmic diagnostic imaging (92133) and the outpatient office visit (99214) provided on
February 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power wheelchair repairs.
You asked the Plan to pre-approve power wheelchair repairs. You say that without the power wheelchair you
are confined to your home. The Plan denied your request. The Plan says the power wheelchair is not covered
for use outside the home.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate
and needed for use inside the home.
The item at issue in this appeal is for use outside of the home. The file indicates you have a manual wheelchair
for use inside the home and these repairs are for a power wheelchair to be used outside the home. Although this
item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we
decided that the Plan does not have to pre-approve power wheelchair repairs.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a prosthesis to include code L5845.
You asked the Plan to provide coverage for code L5845, the additional right knee-shin stance flexion feature.
You say that at the time of the appeal, the requested prosthesis and components were medically necessary. The
Plan denied your request. The Plan says the requested right above the knee prosthesis knee component under
code L5828 (reflected on the order) was requested is for the "Ossur Mauch" knee. The Plan states while several
Ossur knees use code L5845, the " Ossur Mauch" knee is not one of them. Code L5845 cannot be used for this
prosthetic component. Maximus overturned the Plans denial stating the Plan did not confirm the Ossur Mauch
knee was the brand ordered. The Plan requested a reopen and provided additional documentation to show this
was indeed the knee ordered.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. Providers must report services with the appropriate codes. In this case it was
confirmed that the Ossur Mauch knee was ordered, and that code L5845 cannot be used with the Ossur Mauch
knee. Therefore, we decided that the Plan does not have to provide coverage for a leg prosthesis to include code
L5845, the additional right knee-shin stance flexion feature for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF)
admission and services.
You asked the Plan to provide coverage for IRF care. You say that at the time of the appeal, IRF admission was
medically necessary. The Plan denied your request. The Plan says the Medicare coverage criteria were not met.
Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the
correct criteria.
The Plan is correct in this case. 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. Based
on the medical records provided, while IRF care may have been beneficial at the time of the appeal, you did not
meet all of the required coverage criteria for approval of this admission. Your physical condition did not
require and inpatient level of intense rehabilitation.
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to provide coverage for acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay additional reimbursement for vision services and eyewear
provided on May 14, 2022.
You asked the Plan to pay additional reimbursement. You say that you believe the Plan should pay more of the
cost of these services. The Plan denied your request. The Plan says this cost sharing was charged correctly.
Maximus overturned the Plans denial for insufficient explanation of why or how the $136 was calculated. The
Plan requested a reopen and provided additional information. The Plan shows the claim submitted processed
correctly. The Plan states there is a $450.00 benefit allowance to reduce the retail cost. This is the first dollar
amount deducted from the claim. Depending on the amount of the claim, once the benefit allowance has been
exhausted the Plan deducts an additional 20% from the total amount billed. In this case, the provider billed
$620.00. Therefore, $620.00 minus $450.00(benefit allowance) is $170.00 and then minus 20% or $34.00
leaves the enrollee responsibility of $136.
The Plan is correct in this case. 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 the allowance for vision services and eyewear is $450. The Plan has demonstrated this allowance
was applied as well as an additional 20% reduction, leaving a balance owed by you of $136. 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 pay additional reimbursement for vision services and eyewear provided on May 14, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share applied to outpatient laboratory services
provided on February 23, 2022, and May 4, 2022.
You asked the Plan to waive this cost share. You say that you never had these services applied to the deductible
in the past. The Plan denied your request. The Plan says this cost sharing was charged correctly based on the
claim submitted by the provider and the 2022 Plan contract agreement. Maximus overturned the Plans denial
for a lack of Explanation of Benefits documentation in the case file. The Plan requested a reopen and submitted
the required documentation.
The Plan is correct in this case. 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 2022 contract with the Plan
clearly stated you must pay a $395 deductible before certain services were covered by the Plan. You were
asked to pay the correct amount based on your contract with the Plan and the claim for payment submitted by
your provider.
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 outpatient laboratory services provided on February 23, 2022, and
May 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you $1220 paid for dental services (root canal and core
build up) provided on April 22, 2022.
You asked the Plan to reimburse you for these services. You say that you have already submitted this request to
the provider and they refuse to review it. The Plan denied your request. The Plan says the services provided
were not covered under your dental benefit. Maximus overturned the Plans denial for insufficient information
in the case file. The Plan requested a reopen and provided additional information to include medical records
and contract information.
The Plan is correct in this 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 in excess of Medicare coverage, the services provided are not among
those covered under this benefit.
Therefore, we decided that the Plan does not have to reimburse you $1220 paid for dental services (root canal
and core build up) provided on April 22, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided the Plan does not have to pay for inpatient care provided from April 3, 2022, to April 7, 2022.
You asked the Plan to pay for these services. You say that the Plan should pay for the treatment you received
out of the country. The Plan denied your request. The Plan says there is insufficient documentation to support
the reimbursement or payment of these services. Maximus overturned the Plans denial. The Plan requested a
reopen and stated that Maximus did not apply the correct criteria. The Plan states based on the documentation
provided, there is no way of knowing what was actually paid. The Plan notes you were contacted and indicated
you have no other documentation to submit.
The Plan is correct in this case. Medicare only pays for inpatient care or emergency care based on
the three scenarios listed above. The Plan contract provides coverage out of the country as long as the
appropriate documentation is submitted to prove what services were rendered and what was paid for each
service. The documentation submitted for reimbursement is insufficient to show what was actually paid.
Neither the Medicare criteria nor the contractual criteria were met for paymet of these services. Therefore, we
decided that the Plan does not have to pay for inpatient care and medical services provided from
April 3, 2022, to April 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for refractive services provided on April 14, 2022.
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The
Plan denied your request. The Plan says this was not a routine exam and therefore refractive services would not
be covered. Maximus overturned the Plans denial for a lack of medical records in the file. The Plan requested a
reopen and provided additional medical records.
The Plan is correct in this case. Medicare generally does not cover refraction 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 only covers refractive services during a routine eye exam. Based on the medical
records provided and the claim submitted by the provider, this was not a routine eye exam. The Plans
contractual requirements were not met. Therefore, we decided that the Plan does not have to pay for refractive
services provided on April 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for oxygen equipment provided on September 
6, 2022. 
 
You asked the Plan to waive the coinsurance for oxygen equipment. You say that your income is limited, and 
this amount each month will cause a hardship. 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 20% 
coinsurance for durable medical equipment (DME) and related supplies. The allowed amount of this item is 
$139.63, resulting in a coinsurance amount of $27.93 ($139.63 x 20% = $27.93). 
 
You have been asked to pay a $27.93 coinsurance for oxygen equipment. This item/service falls within the 
durable medical equipment (DME) and related 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 coinsurance for oxygen equipment provided on September 6, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial upper denture (D5213) and a partial lower 
denture (D5214). 
 
You asked the Plan to pre-approve the dental services. You say that the old dentures hurt your mouth and you 
went to a new dentist to get different dentures approved. The Plan denied your request. The Plan says your 
benefit for the requested items or services 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 items or service was exhausted on the date of service of July 6, 2021. 
Therefore, we decided that the Plan does not have to pre-approve a partial upper denture (D5213) and a partial 
lower denture (D5214).  
 Your complaint about the prior providers customer service and wait times 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial upper denture (D5213). 
 
You asked the Plan to pre-approve the dental service. You say that you need the denture as soon as possible. 
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 the date of service of April 30,2021. 
Therefore, we decided that the Plan does not have to pre-approve a partial upper denture (D5213).
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 enrollee requires therapies that are 
not able to be met in the short term acute hospital where the enrollee is currently receiving care. The Plan 
denied your request. The Plan says we will continue to cover medically necessary acute and critical care at the 
current facility until the enrollee's condition is stable for transfer to an alternate level of care. 
 
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 is receiving the appropriate care at the present acute care hospital. There 
are no services available at the LTACH that the enrollee requires that are not available at the health care setting 
being offered by the health plan. Continued care at the current facility is recommended. 
 
 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: 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 services are medically necessary as 
all of the services the enrollee needs cannot be met at the short term acute care hospital where they are 
currently. The Plan denied your request. The Plan says the enrollee does not require complex medical care or 
management. 
 
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 stable and improving on current treatments. The enrollee 
does not require services at the LTACH that are not already available at the current facility. Completion of 
treatment at the current facility is recommended. 
 
 
 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81439 provided on September 21, 2021. 
 
You asked the Plan to pay for procedure code 81439. 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 test at issue in this appeal, procedure code 81439, was requested solely for screening purposes. Medicare 
does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay 
for procedure code 81439 provided on September 21, 2021.