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

We decided that the Plan does not have to pre-approve Udenyca for the enrollee.
You asked the Plan to pre-approve Udenyca. You say that this drug is medically necessary. The Plan denied your request. The Plan says 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.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for Udenyca (Pegfilgrastim-cbqv). The Maximus Physician Reviewer determined that the enrollee had a greater than 20% risk of neutropenic fever with the use of carboplatin and pemetrexed, given the enrollee's age greater than 65 and prior chemotherapy. Udenyca was determined to be reasonable and medically necessary to minimize risk. The Plan requested a reopen and argues that Carboplatin/pemetrexed for the treatment of metastatic non-small cell lung cancer is considered a low risk of developing neutropenic fever per NCCN Guidelines for the Management of Neutropenia v.1.2022. The plan notes that there are no recommendations for the use of growth factor/G-CSF support in patients being treated with carboplatin/pemetrexed in any disease state. The Plan states there is no literature evidence to suggest carboplatin/pemetrexed in patients with metastatic non-small cell lung cancer, regardless of risk factors, would be considered intermediate or high-risk for neutropenic fever.
The medical records show the enrollee is a 67-year-old woman with a diagnosis of metastatic Stage IV non-small cell lung cancer with recurrence following palliative radiation therapy, chemotherapy, and Keytruda (Pembrolizumab). The proposed treatment regimen was to include Pembrolizumab, Carboplatin, and Pemetrexed. Udenyca is indicated for the prophylaxis of febrile neutropenia in patients with non-myeloid malignancies receiving myelosuppressive anti-cancer drugs with a clinically significant incidence of febrile neutropenia. The Plan is correct in this case. The documentation does not support that Udenyca (Pegfilgrastim-cbqv) was medically reasonable and necessary for the enrollee in this case, as the planned regimen was not considered high or intermediate risk for the development of febrile neutropenia. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Udenyca have not been met. Therefore, we decided that the Plan does not have to pre-approve Udenyca for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 4 additional intraoral x-rays (D0230, D0220) provided on 
October 26, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. 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 date of service October 26, 2022. 
Therefore, we decided that the Plan does not have to pay for 4 additional intraoral x-rays (D0230, D0220) 
provided on October 26, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for x-ray services and a specialist office visit 
provided on September 19, 2022. 
 
You asked the Plan to waive the copayment for x-ray services and a specialist office visit. You say that you 
disagree with the copayments. 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 outpatient diagnostic tests/x-rays and a $30 copayment for physician/practitioner services/ 
specialist.  
 
You have been asked to pay a $30 copayment for x-ray services and a $30 copayment for a specialist office 
visit. This item/service falls within the outpatient diagnostic tests/x-rays and physician/practitioner services/ specialist benefit category. The total amount you are being asked to pay is $60 ($30 + $30 =$60). 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 x-ray services and a specialist office visit provided on September 19, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (K0553) provided on 
September 21, 2022. 
 
You asked the Plan to pay for the continuous glucose monitor. You say that this item was medically necessary. 
The Plan denied your request. The Plan says the documentation does not support the billed item. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. The 
shipping/delivery date does not match the date of service on the claim. The record shows that the Plan made 
several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan 
does not have to pay for a continuous glucose monitor (K0553) provided on September 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Continuous Positive Air Pressure machine (E0601) 
provided on December 4, 2021. 
 
You asked the Plan to pay for the Continuous Positive Air Pressure machine. You say that these items were 
medically necessary. The Plan denied your request. The Plan says the billing provider is not eligible for 
payment for this item. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. For durable medical equipment, claims must contain an enrolled 
Medicare Supplier Number. 
 Review of the file and Medicare records indicates that the provider at issue does not have a Medicare enrolled 
supplier number. Records show this provider's specialty as sleep medicine, not a DME supplier. Therefore, we 
decided that the Plan does not have to pay for a Continuous Positive Air Pressure machine (E0601) provided on 
December 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient wound surgery provided by 
an in-network provider on October 20, 2022, October 24, 2022, and October 28, 2022. 
 
You asked the Plan to waive the copayment for the outpatient wound surgeries. You say that you do not agree 
with the cost sharing applied to these services. 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 in-network Medicare-covered outpatient hospital surgery services. 
 
 
 
 
 
 You have been asked to pay a $450 copayment for the outpatient wound surgeries ($150 x 3 services = $450). 
These items/services fall within the outpatient surgery, including services provided at hospital outpatient 
facilities and ambulatory surgical centers benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for the outpatient wound surgery provided by an in-network provider on October 20, 2022, October 24, 2022, 
and October 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), a comprehensive 
series of radiographic images (D0210), panoramic radiographic images (D0330), and 2D oral photographic 
images (D0350), provided by December 6, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told that this would be paid in full. 
The Plan denied your request. The Plan says your benefit for D0150, D0210 and D0330 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 D0150, D0210, and D0330 was exhausted on date of service February 24, 2022. D0350 
is not a covered dental benefit. Therefore, we decided that the Plan does not have to pay for a comprehensive 
oral evaluation (D0150), a comprehensive series of radiographic images (D0210), panoramic radiographic 
images (D0330), and 2D oral photographic images (D0350), provided by December 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional $40 for the eyeglasses provided on May 6, 2022.
You asked the Plan to pay an additional $40 for the eyeglasses. You say that you overpaid for the vision services. The Plan denied your request. The Plan says that the Plan paid the correct $100 allowance.
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 a $100 benefit toward the purchase and fitting of eyeglasses and pair of lenses or contact lenses. We looked at the file and the Plan's rules. The total cost charged was $266. The Plan then paid $100 leaving $166. A 20% discount ($33.20) was then applied leaving a balance of $132.80 that you are responsible for. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay an additional $40 for the eyeglasses provided on May 6, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Medicare Part B Prescription Drugs 
provided on September 27, 2022. 
 
You asked the Plan to waive the coinsurance for Medicare Part B Prescription Drugs. You say that you 
disagree with the coinsurance. 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 Medicare Part B Prescription Drugs.  
 
You have been asked to pay a 20% coinsurance for Medicare Part B Prescription Drugs. The total allowed 
amount for the prescription drugs is $1,598.80. You are being asked to pay $319.76 ($1,598.80 x 20% = 
$319.76). This item/service falls within the Medicare Part B Prescription Drugs benefit category. This means 
that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for Medicare Part B Prescription Drugs provided on September 27, 
2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on October 5, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you would 
like a review and reconsideration. The Plan denied your request. The Plan says these services are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on October 5, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on October 5, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on 
September 14, 2022, to September 29, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you disagree with the 
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 $275 
copayment per day for days 1-5 and a $0 copayment per day for days 6-90 for inpatient hospital care.  
 
You have been asked to pay a $275 copayment per day for days 1-5 and a $0 copayment per day for days 6-90 
for inpatient hospital care. The total amount you are being asked to pay is $1,375 ($275 x 5 days = $1,375). 
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 inpatient hospital care provided on September 14, 2022, to September 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete 
series of x-rays (D0210) provided on October 28, 2022. 
 
You asked the Plan to pay for the dental services. You say that you required these services earlier in the year 
during a dental emergency and needed them again as a new patient with a different provider. 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 date of service June 20, 2022. Therefore, 
we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete 
series of x-rays (D0210) provided on October 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewing x-rays (D0272) provided on November 1, 2022. 
 
You asked the Plan to pay for the x-rays. You say that the x-rays you received in July were part of a regular 
check-up. You also say that the x-rays you received in November were medically necessary for re-cementing a 
crown. 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 date of service July 18, 2022. Therefore, 
we decided that the Plan does not have to pay for the bitewing x-rays (D0272) provided on November 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral x-ray (D0210) provided on August 5, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an 
intraoral x-ray (D0210) provided on August 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oral exam (D0140) and an additional tooth for a denture 
(D5650) provided on October 31, 2022. 
 
You asked the Plan to pay for the dental services. You say that these dentures do not fit properly. The Plan 
denied your request. The Plan says your benefit for D0140 has already been exhausted. The Plan says there is 
no dental coverage for D5650. 
 
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 D0140 was exhausted on date of service February 2, 2022. D5650 is not a covered 
dental benefit. Therefore, we decided that the Plan does not have to pay for an oral exam (D0140) and an 
additional tooth for a denture (D5650) provided on October 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on October 28, 
2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
periodontal maintenance (D4910) provided on October 28, 2022.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa for the enrollee.
You asked the Plan to pre-approve Euflexxa. You say that you disagree with the denial. The Plan denied your request. The Plan says that you didn't indicate a valid reason why Orthovisc or Supartz FX would be inappropriate/ineffective for this member.
Our Medical director looked at the case file and the reopen request. At issues is coverage for Euflexxa. Our Medical Director states that the available clinical records do not support that Orthovisc or Supartz FX has been tried and failed. The documentation does not support that Orthovisc or Supartz FX would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for Euflexxa. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa for the enrollee.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pelvic ultrasound provided on June 01, 2022. 
 
You asked the Plan to pay for a pelvic ultrasound. You say that this was medically necessary and should be 
covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a pelvic ultrasound 
provided on June 01, 2022.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health care billed to the enrollee from September 11, 2021, to October 10, 2021.
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 the Medicare billing criteria were not met. Maximus overturned the Plans denial for insufficient information regarding the denial. The Plan requested a reopen and provided additional explanation.
The Plan noted that this claim denied because the provider billed this service with Bill Type 327 for Home Health Agency/Inpatient/Replacement of Prior Claim with code Q5001 which indicates hospice or home health care was being provided in the enrollee's home or legal residence. The case file includes the appealed claim that shows the inappropriate billing from the provider.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The claim submitted shows the first date of service as September 11, 2021. The first time the Q code of Q5001 was reported was on September 23, 2021. The code was not reported on the correct initial date. Medicare billing criteria were not met. Therefore, we decided that the Plan does not have to pay for home health care billed to the enrollee from September 11, 2021, to October 10, 2021.