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

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the SNF admission. You say that the requested admission to a SNF is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a SNF is not 
medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the SNF admission. Our reviewer says 
that the enrollee does not meet the Medicare criteria for SNF care. Our physician reviewer found daily skilled 
services are not required to establish a maintenance program or to prevent deterioration of the enrollees 
condition. The enrollees care needs, as a practical matter, can be provided at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for the dispensing fee, monaural hearing 
aid (V5241), ear mold/insert, not disposable (V5264), and hearing aid, digital, monaural, behind the ear 
(V5257) provided March 14, 2022. 
 
You asked the Plan to provide additional payment for the dispensing fee, ear mold/insert and hearing aids. You 
say that you were told $500 would be paid. The Plan denied your request. The Plan says your remaining 
hearing benefit was applied to the claim, and no further payment is due. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only up to $500 every 3 years.  
 
We looked at the file and the Plan's rules. The Plan provided documentation showing that $300 was applied 
towards the repair of a hearing aid on August 7, 2020. Your remaining $200 hearing aid allowance was applied 
to the hearing aids purchased March 14, 2020. You have been asked to pay the amount above the hearing aid 
benefit. Therefore, we decided that the Plan does not have to provide additional payment for the dispensing fee, 
monaural hearing aid (V5241), ear mold/insert, not disposable (V5264), and hearing aid, digital, monaural, 
behind the ear (V5257) provided March 14, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an X-Ray on January 3, 2022. 
 
You asked the Plan to waive the copayment for an X-Ray. You say that you would like to appeal the cost share. 
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 enrollees contract with the Plan clearly says that enrollees 
must pay a $110 copayment for an X-Ray.  
 
The enrollee has been asked to pay a $110 copayment for an X-Ray. An X-Ray falls within the Outpatient 
diagnostic tests and therapeutic services and supplies 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 an X-Ray on January 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services on November 16, 2021. 
 
You asked the Plan to waive the copayment for laboratory services. You say that you would like to appeal the 
cost share. 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). Your contract with the Plan clearly says that you must pay a $15 
copayment for laboratory services.  
 
You have been asked to pay a $15 copayment for laboratory services. Laboratory services 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 laboratory services on November 16, 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 enrollee is expected to require 
another 3-4 weeks to continue weaning from ventilator and to transition from her acute illness. The Plan denied 
your request. The Plan says criteria for admission to the LTACH have not been met. The enrollee's medical 
needs are being met in the current acute setting. 
 
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 that in this case the enrollee was admitted with upper extremity cellulitis and suffered 
a cardiac arrest with resultant anoxic brain injury. The record indicates that the enrollee requires pressor 
support and other acute care services. The enrollee continues to receive acute care services, and these have not 
been denied.  The medical record does not indicate that the enrollee requires services that she is not currently 
receiving but that would be available at the LTACH facility. The elements of the coverage rules are not 
satisfied. The requested service cannot be 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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for dialysis provided from October 7, 2020, and October 26, 2020. 
 
You asked the Plan to pay for the dialysis. You say that the claim denied but the enrollee did not receive any 
injections, only dialysis. The Plan denied your request. The Plan says that reporting the value 99.99 is not 
permitted when billing for an ESA. The Plan also says the claim should be billed with Q4081 or J0882 codes 
along with a JA or JB modifier. 
 
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 rules cited for denying this claim only apply when an enrollee is receiving 
Erythropoiesis-stimulating agents (ESAs). There is no evidence the enrollee received ESAs and the Plan did 
not provide another reason for denying payment. It is the burden of the Health Plan to substantiate their denial 
with evidence. In this case, the denial has not been substantiated so we must find in your favor. Therefore, we 
decided that the Plan has to pay for dialysis provided from October 7, 2020, and October 26, 2020.  
 
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: Unfavorable

 
We decided that the Plan does not have to pre-approve Alprostadil. 
 
You asked the Plan to pre-approve Alprostadil. You say that you would like the plan to reconsider their 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 pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 Alprostadil. 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 Peyronies disease. The Food and Drug Administration has not 
stated that the requested drug is indicated for the enrollee's condition. The Medicare approved 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 Alprostadil have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Alprostadil.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a biopsy performed on March 15, 2022. 
 
You asked the Plan to waive the copayment for a biopsy. You say that you should not be responsible for the 
cost share because this service was provided in a doctor's office. The Plan denied your request. The Plan says 
you must pay a $350 copayment for surgery in an outpatient hospital setting. 
 
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 enrollees contract with the Plan clearly says that enrollees 
must pay a $350 copayment for Outpatient Surgery, Including Services Provided At Hospital Outpatient 
Facilities and Ambulatory Surgical Centers.  
 
The enrollee has been asked to pay a $350 copayment for a biopsy. A biopsy falls within the Outpatient 
Surgery, Including Services Provided At Hospital Outpatient Facilities and Ambulatory Surgical Centers 
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 a biopsy performed on March 
15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on March 31, 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 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 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 the laboratory 
services provided on March 31, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (80069, 82728, 83540, 83550) provided January 
13, 2022. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the codes billed are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab 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 
lab services (80069, 82728, 83540, 83550) provided January 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (0037U) provided January 9, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says this type of genetic testing is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that genetic testing panels that include the FANCC 
genes are non-covered. 
 
We looked at the file and Medicare rules. The panel included the FANCC gene and is non-covered. Based on 
this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, 
we decided that the Plan does not have to pay for lab services (0037U) provided January 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction (92015) provided on February 16, 2022. 
 
You asked the Plan to pay for the eye refraction. You say that you went to an in-network provider for a diabetic 
eye exam, and are being asked to pay an additional $49 that you were not informed of, did not need, or want. 
The Plan denied your request. The Plan says this vision service is not covered. 
 
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 these services when the refraction is billed as part of the routine eye exam. 
 
We looked at the file and the Plan's rules. The record shows that you received a medical eye exam, and not a 
routine eye exam. Based on this information, we decided that the Plan's rules for coverage of the eye refraction 
have not been met. Therefore, we decided that the Plan does not have to pay for the eye refraction (92015) 
provided on February 16, 2022.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for a home COVID-19 test purchased on January 18, 2022.
You asked the Plan to pay for this testing. You say that this test kit should be paid for by the Plan. The Plan
denied your request. The Plan says this test is covered by Original Medicare. Maximus overturned the Plans
denial. The Plan requested a reopen and stated that Maximus did not apply the correct coverage criteria. The
Plan states that contract addendum coverage sent to all enrollees indicated coverage for home tests would be
provided beginning on February 1, 2022. This purchase does not qualify for that benefit.
The Plan is correct in this case. The Plan follows Medicare rules. The rules say that Plans were given the option
to cover home testing kits as a supplemental benefit but were not required to do so by Medicare.
The Plan communicated to enrollees that this testing would be covered supplementally free of charge after
February 1, 2022. Therefore, we decided that the Plan does not have to pay for a home COVID-19 test
purchased on January 18, 2022.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for a home COVID-19 test purchased on January 18, 2022.
You asked the Plan to pay for this test. You say that this test should be covered by the Plan. The Plan denied
your request. The Plan says at the time of purchase this test was not covered. Maximus overturned the Plans
denial. The Plan requested a reopen and stated that Maximus did not apply the correct coverage criteria.
The Plan is correct in this case. Medicare gave health Plans the option to cover home COVID-19 testing as a
supplemental benefit. The Plan did not begin coverage for home test kits until February 1, 2022. This test was
purchased prior to the beginning of this benefit. Therefore, we decided that the Plan does not have to pay for a
home COVID-19 test purchased on January 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on January 7, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the service was medically necessary. The Plan 
denied your request. The Plan says no prior authorization was obtained. 
 
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 did not pre-approve the 
office visit. We found no exception that would require the Plan to pay for the office visit. The records provided 
for review do not show that the office visit was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the office visit provided on January 7, 2022, by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on January 17, 2022. 
 
You asked the Plan to pay for lab testing. You say that these tests are pertinent for the end-stage renal disease 
(ESRD) patient. The Plan denied your request. The Plan says the denial of payment for this testing is correct, 
because lab testing related to treatment of ESRD is bundled into dialysis services and is not separately 
reimbursable. 
 
The Plan must follow Medicare rules. Medicare rules say that lab tests furnished to individuals for the 
treatment of end-stage renal disease (ESRD) are included in the ESRD prospective payment system (PPS) and 
are not paid separately.  
 
We looked at the file and Medicare rules. This lab testing was related to treatment of ESRD; therefore, 
payment for the testing is included in the ESRD PPS payment and is not paid separately. Based on this 
information, we decided that Medicare rules for coverage of lab testing have not been met. Therefore, we 
decided that the Plan does not have to pay for laboratory testing provided on January 17, 2022.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to waive the copayment for a specialist visit. We decided that the Plan does not 
have to waive the 20% coinsurance on medical supplies.  
 
You asked the Plan to waive the copayment for a specialist visit. You say that you should not be charged for 
the specialty copayment, as you did not see the provider, but got an at home INR kit. The Plan says that the 
copayment applied was correct. We decided that the Plan has to waive the copayment for a specialist visit.  
 
The Plan follows Medicare rules. Medicare rules say that specialist visits have a $45 copayment.  
 
The file shows that you have a medical indication for which Medicare will cover medical supplies at a 20% 
coinsurance. Therefore, we decided that the Plan has to waive the copayment for a specialist visit.  
 
We also decided that the Plan does not have to waive the coinsurance for an at home INR kit. 
 
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 20% 
coinsurance for medical supplies. Therefore, we decided that the Plan does not have to waive the coinsurance 
for an at home INR kit. The allowed amount of this kit is $116.67 resulting in a coinsurance amount of $23.33. 
 
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: Unfavorable

 
We decided that the Plan does not have to pre-approve Tecentriq. 
 
You asked the Plan to pre-approve Tecentriq. You say that the enrollee has resected non-small cell lung cancer, 
and he should be a candidate for coverage of the requested drug. The Plan denied your request. The Plan says 
they do not see support for monotherapy Tecentriq in patients with no prior chemotherapy. 
 
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 Tecentriq. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the requested drug is FDA approved as 
adjuvant treatment (as a single agent) following resection and platinum-based chemotherapy in adults with 
stage II to IIIA non-small cell lung cancer whose tumors have PD-L1 expression on less than or equal to 1% of 
tumor cells, as determined by an approved test. This enrollee has no received platinum-based chemotherapy 
and is only a stage IB. The use of the requested drug in this clinical scenario is not supported by one of the 
major drug compendia or by clinical research that appears in a CMS-approved medical journal.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Tecentriq have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Tecentriq.