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

 
We decided that the Plan does not have to pay for nursing facility care provided on April 8, 20225, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for nursing facility care. You say that you are appealing the claim payment denial. 
The Plan denied your request. The Plan says the services were provided out-of-network and were not approved 
in advanced. 
 
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 items/services at issue in this appeal. The Plan did not pre-approve the 
item/service 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 nursing facility care provided on April 8, 20225, 
by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the colonoscopy with biopsy provided on 
May 10, 2022. 
 
You asked the Plan to waive the copayment for the colonoscopy with biopsy. You say that you did not agree to 
the enhanced procedure. 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 $150 
copayment for outpatient hospital facility visits. 
 
You have been asked to pay a $150 copayment for the colonoscopy with biopsy. This item/service falls within 
the outpatient hospital facility 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. The records show two polyps were removed during the procedure. For this 
reason, the procedure is considered diagnostic. Therefore, we decided that the Plan does not have to waive the 
copayment for the colonoscopy with biopsy provided on May 10, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on December 17, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered as billed. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for the laboratory services by a contract provider. The file does not show that the 
plan provided notice that the laboratory services would not be covered. Under Medicare rules, this means the 
laboratory services are considered approved by the plan. Therefore, we decided that the Plan has to pay for the 
laboratory services provided on December 17, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the deductible for the x-rays and magnetic resonance imaging 
(MRI) of the spine provided on May 27, 2022. 
 
You asked the Plan to reduce the deductible for the x-rays and magnetic resonance imaging (MRI) of the spine. 
You say that you feel the copayments were calculated incorrectly. 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 $500 
deductible for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $500 deductible for the x-rays and magnetic resonance imaging (MRI) of the 
spine. This item/service falls 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 reduce the deductible for the x-rays and magnetic resonance imaging 
(MRI) of the spine provided on May 27, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for physical therapy (PT) services provided 
from December 29, 2021, to March 1, 2022. 
 
You asked the Plan to waive the copayments for the physical therapy (PT) services. You say that you would 
like these claims reimbursed. 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 $30 
copayment for physical therapy and/or speech and language pathology.  
 
You have been asked to pay a $30 copayment for each of the physical therapy (PT) services. The file shows 11 
visits from December 29, 2021, to March 1, 2022, for a total of $330. This item/service falls within the 
physical therapy and/or speech and language pathology benefit category. This means that you have been asked 
to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive 
the copayments for physical therapy (PT) services provided from December 29, 2021, to March 1, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Evenity (J3111). 
 
You asked the Plan to pre-approve Evenity. 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 Evenity. 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 drug Forteo before they will approve a new start of the requested drug. In this case, the 
enrollee has not tried and failed the required drug. There is no documentation provided indicating that the 
Plans required drug would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve treatment with Evenity (J3111).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided on July 
05, 2022, to July 08, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital care. You say that you should have been 
discharged on July 6, 2022. 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 $975 
copayment for inpatient hospital care. 
 
You have been asked to pay a $975 copayment for the inpatient hospital care. This item/service 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. Per the EOC, there is a $325 copayment per day for days 1-6 of inpatient care per 
admission. Your stay lasted 3 days from July 5, 2022, to July 8, 2022, for a total of $975. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient hospital care provided on July 05, 
2022, to July 08, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on May 19, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on May 19, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MVASI. 
 
You asked the Plan to pre-approve MVASI. 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 must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 MVASI. 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 a diagnosis of metastatic Non-Small Cell Lung Cancer with PDL expression of 
20% and who had disease progression on chemotherapeutic regimens containing Keytruda. The Food and Drug 
Administration has not stated that the requested drug is indicated for the enrollee's condition. The Medicare 
approved cancer drug compendia do not contain a supportive citation for the use of the requested drug in the 
enrollee's clinical situation. Therefore, the enrollee does not meet criteria for the requested drug. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MVASI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve MVASI.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 64493, 64494, 64495, 64493, and 27096 provided on 
April 12, 2022. 
 
You asked the Plan to pay for procedure codes 64493, 64494, 64495, 64493, and 27096. You say that you 
would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the 
services are not covered. 
 
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. In this case, the Plan originally denied payment for these services due to "charge 
exceeds fee schedule/maximum allowable and missing/incomplete/invalid/inappropriate place of service." On 
appeal, the Plan rationale for denial is that a primary EOB was not obtained. The Plan has not made clear what 
the denial reasoning is in this case. The Plan has provided no Medicare regulations to substantiate their 
reasoning for denial. Therefore, we decided that the Plan has to pay for procedure codes 64493, 64494, 64495, 
64493, and 27096 provided on April 12, 2022.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the electrocardiogram (EKG) provided on 
May 19, 2022. 
 
You asked the Plan to waive the copayment for the electrocardiogram (EKG). You say that the EKG should be 
included in the office visit copayment. 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 $13.91 
copayment for diagnostic procedures or tests at a network doctors office. 
 
You have been asked to pay a $13.91 copayment for the electrocardiogram (EKG). This item/service falls 
within the diagnostic procedures or tests at a network doctors office 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. The allowed amount for the EKG is 
$13.91. Since this is less than the $65 copayment per the EOC, you are only responsible for the lesser amount. 
Therefore, we decided that the Plan does not have to waive the copayment for the electrocardiogram (EKG) 
provided on May 19, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the complete pelvic ultrasound provided 
on June 17, 2022. 
 
You asked the Plan to reduce the copayment for the complete pelvic ultrasound. You say that you should only 
have a $40 specialist copayment. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 
copayment for basic imaging services (x-rays and ultrasounds). 
 
You have been asked to pay a $45 copayment for the complete pelvic ultrasound. This item/service falls within 
the basic imaging services (x-rays and ultrasounds) 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 reduce the 
copayment for the complete pelvic ultrasound provided on June 17, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that admission to IRF care is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee's needs can be met at a lower level of care. 
 
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 there are no complex nursing or rehabilitation needs. While the enrollee has a need 
for physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. 
 
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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compressor, segmental home model 
without calibrated gradient pressure (E0651) and full leg garments (E0667). 
 
You asked the Plan to pre-approve intermittent limb compression device. You say that the enrollee has 
medically necessary and appropriate reasons requiring use of the pneumatic compression pump. She is 
diagnosed with lymphedema and presents with swelling in her bilateral legs along with impaired 
ROM/mobility, pain, hyperpigmentation, and a history of compromised skin integrity/ ulcers. The Plan denied 
your request. The Plan says pneumatic pumps are covered for treatment of lymphedema if it is unresponsive to 
other treatment over a four (4) week period. Medicare LCD criteria are not met as the submitted documentation 
indicates that the enrollee's lymphedema has been responsive to other clinical treatment over a four (4) week 
trial, evidenced by decreased swelling and wound healing. Medical necessity is not established. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
 
 
 
 
 
 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 intermittent limb compression device. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found provided records 
from June 28, 2022, document improvement in the enrollee's lower extremity swelling and resolution of her 
venous insufficiency ulcers with conservative treatment with an Unna boot. As stated in the Local Coverage 
Determination (LCD), at the end of the four-week trial of conservative therapy, if there has been improvement, 
then reimbursement for a pneumatic compression device is not justified. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of intermittent limb compression device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a pneumatic compressor, segmental home model without calibrated 
gradient pressure (E0651) and full leg garments (E0667).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for cardiac rehabilitation services provided 
from May 10, 2022, to May 31, 2022. 
 
You asked the Plan to waive the copayment for cardiac rehabilitation services provided. You say that if you 
had known how costly these services would be, you would not have started the program. 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 
copayment for cardiac rehabilitation services ($20 per visit x 7 visits = $140).  
 
You have been asked to pay a $140 copayment for cardiac rehabilitation services provided. This item/service 
falls within the cardiac rehabilitation 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 cardiac rehabilitation services provided from May 10, 2022, to May 31, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient stay provided from March 19, 
2022, to March 22, 2022. 
 
You asked the Plan to waive the copayment for an inpatient stay. You say that you had received terrible care at 
this facility and would like this copayment 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 $300 
copayment per day for days 1-5 for inpatient hospital care ($300 x 2 = $600).  
 
You have been asked to pay a $600 copayment for an inpatient stay. This item/service 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 an inpatient stay provided 
from March 19, 2022, to March 22, 2022.  
 Maximus read your letter and knows that you may have a quality of care concern. Maximus cannot address 
quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement 
Organization for further review.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a CGM. 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. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor (CGM).