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

 
We decided that the Plan does not have to pre-approve two (2) injections of Sclerosant.  
You asked the Plan to pre-approve two (2) injections of Sclerosant. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Sclerosant is only covered for certain indications. 
 
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 two (2) injections of Sclerosant. Our 
reviewer says that the documentation does not support that the requested services are medically reasonable or 
necessary. Our physician reviewer found the enrollee has varicose veins. The record does not include 
documentation of failure of conservative therapy. The record indicates compression stockings were ordered in 
June. Therefore, the enrollee does not meet criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of two (2) injections of Sclerosant have not been met. Therefore, we decided that 
the Plan does not have to pre-approve two (2) injections of Sclerosant.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for diagnostic testing provided on November 8, 
2021, and December 13, 2021. 
 
You asked the Plan to waive the copayment for diagnostic testing. You say that you were told there would be 
no charge for this. 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 $45 
copayment for diagnostic procedures and tests.  
 
You have been asked to pay $45 copayment for diagnostic testing. Diagnostic testing 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 waive the copayment for diagnostic testing provided on November 8, 2021, and December 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Toradol injection on March 21, 2022. 
 
You asked the Plan to waive the coinsurance for a Toradol injection. You say that  you needed this service by 
an in-network provider because your back was hurt during your mammogram. You say that you would like the 
provider to pay for this service. The Plan denied your request. The Plan says there is a 20% coinsurance for 
Medicare Part B prescription drugs. 
 
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. The allowed amount of the claim is $17.53, resulting in a 
coinsurance amount of $3.51 ($17.53 x 20% = $3.51). A Toradol injection 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 Toradol injection on 
March 21, 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: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Actemra IV for the enrollee. 
 
You asked the Plan to pre-approve Actemra IV. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the request for Actemra IV for a diagnosis of Interstitial lung disease is not an FDA 
approved or compendia supported indication. 
 
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 Actemra IV. Our reviewer says that 
Actemra IV is medically reasonable and necessary. This patient has progressive interstitial lung disease related 
to scleroderma-like connective tissue disease. Actemra is FDA approved for this indication. Our physician 
reviewer found that the enrollee's condition meets criteria for coverage of Actemra IV. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Actemra IV have not been met. Therefore, we decided that the Plan has to pre-
approve Actemra IV for the enrollee.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory work provided on March 11, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the laboratory work. You say that the enrollee does not come to the lab which 
means they are not using their out-of-network benefits. You say the participating doctors sends the specimen. 
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 
laboratory work. We found no exception that would require the Plan to pay for the laboratory work. The 
records provided for review do not show that the laboratory work was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for laboratory work provided on March 11, 2022, by an out-of-
network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (82728, 83540, 83550, 83970) provided 
February 3, 2021. 
 
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 services 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 (82728, 83540, 83550, 83970) provided February 3, 2021.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pay for the occupational therapy (OT) services provided on February 22, 2022. 
 
You asked the Plan to pay for the OT services. You say that this claim should have been paid because it was 
visit number nine of 20 approved visits. The Plan denied your request. The Plan says that a case decision was 
not rendered within the appeal timeframe. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not provide any medical records for this case. Without this 
information we cannot determine that services were not medically necessary. The Plan also did not provide 
proof of any visits that were or were not authorized. Consequently, the Plan has not substantiated their denial of 
payment in this case. Therefore, we decided that the Plan has to pay for the occupational therapy (OT) services 
provided on February 22, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for wheelchair and accessories provided on 
February 21, 2022, and March 21, 2022. 
 
You asked the Plan to waive the coinsurance for wheelchair and accessories. You say that you were told this 
would be covered. The Plan denied your request. The Plan says the coinsurance 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 20% 
coinsurance for durable medical equipment.  
 
You have been asked to pay $243.41 which is 20% of the allowed amount for wheelchair and accessories. The 
allowed amount is $1,217.04 (20% x $1,217.04=$243.41). Wheelchair and accessories 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 wheelchair and accessories provided on February 21, 2022, and March 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tear duct closure procedure provided on February 23, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the tear duct closure procedure. You say that you have been getting this 
procedure done for over ten years without needing a referral. You say obtaining a referral is unnecessary 
paperwork. 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 
tear duct closure procedure. We found no exception that would require the Plan to pay for the tear duct closer 
procedure. Therefore, we decided that the Plan does not have to pay for the tear duct closure procedure 
provided on February 23, 2022, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for a home COVID-19 test kit purchased on January 15, 2022.
You asked the Plan to pay for this test kit. The Plan denied your request. The Plan says these test kits were not
authorized to be covered by health Plans on the date of purchase. 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. The Plan must follow Medicare rules. Medicare excludes screening tests from
coverage. At the time of purchase, home COVID-19 tests kits were not covered under your insurance.
Therefore, we decided that the Plan does not have to pay for a home COVID-19 test kit purchased on January
15, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for injection on February 28, 2022. 
 
You asked the Plan to waive the coinsurance for injection. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says the cost-sharing you are being charged is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for Medicare Part B drugs. These drugs are covered under Part B of Original Medicare. Members 
of our plan receive coverage for these drugs through our plan. Covered drugs include: Drugs that usually arent 
self-administered by the patient and are injected or infused while you are getting physician, hospital outpatient, 
or ambulatory surgical center services. The provider billed in the amount of $4,980 and the allowed amount is 
$1,272.60. The Plan paid $1,018.08. $1,272.60 - $1,018.08 = $254.52. Therefore, results in the total cost-
sharing amount of $254.52.  
 
 
 
 You have been asked to pay a 20% coinsurance for injection. Injection 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 injection on 
February 28, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires and is motivated to complete a 
more intensive therapy program than what is offered at most skilled nursing facilities. The Plan denied your 
request. The Plan says based on Medicare guidelines, the IRF services requested do not meet the requirements 
for approval. 
 
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 the complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our physician 
reviewer also found that the patient does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. Our physician reviewer also 
found that medically necessary care can be provided in a different 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital outpatient clinic visit laboratory work provided 
on February 8, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for hospital outpatient clinic visit and the laboratory work. You say that the enrollee 
had an appointment to establish care and for a routine physical prior to becoming effective with the Plan. You 
say you were not advised until after the appointment that the enrollee has a different plan. 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 
hospital outpatient clinic visit and the laboratory work. We found no exception that would require the Plan to 
pay for the hospital outpatient clinic visit and the laboratory work. The record shows CPT code 36415 was 
billed which means the provider had the opportunity to confirm insurance coverage and authorization. 
Therefore, we decided that the Plan does not have to pay for the hospital outpatient clinic visit laboratory work 
provided on February 8, 2022, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gel-One. 
 
You asked the Plan to pre-approve Gel-One. The Plan denied your request. The Plan says this 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 Gel-One. Our reviewer says that Gel-
One is not medically reasonable and necessary in this case. Our physician reviewer found that the records do 
not document trial and failure of an intra-articular corticosteroid injection. Although there may be a transient 
elevation in blood glucose levels after an intra-articular corticosteroid injection, diabetes is not listed as a 
contraindication to its use. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gel-One have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gel-One.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on January 4, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for psychotherapy. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network, and it was 
determined these services can be received in-network. 
 
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 psychotherapy provided on January 4, 2022, by an 
out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the glasses provided on March 5, 2022. 
 
You asked the Plan to pay for the glasses. You say that you would like to be reimbursed the full $500 for your 
glasses. The Plan denied your request. The Plan says you have met the benefit maximum for this service. 
 
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 up to $500 for eyeglasses every 12 months. 
 
We looked at the file and the Plan's rules. The record shows that the Plan paid $400 for eyewear on May 4, 
2021, and you received a $100 reimbursement for the March 5, 2022, date of service, which has exhausted your 
eyewear benefit. Based on this information, we decided that the Plan's rules for coverage of the glasses have 
not been met. Therefore, we decided that the Plan does not have to pay for the glasses provided on March 5, 
2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Neupogen. 
 
You asked the Plan to pre-approve Neupogen. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says the enrollee has not tried and failed the preferred step therapy drugs. 
 
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 Neupogen. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the Plan requires a trial of drugs 
Nivestym and Zarxio before they will approve the requested drug. In this case, the patient has not tried and 
failed the required drug(s). There is no documentation provided indicating that the plans required drug(s) 
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 Neupogen have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Neupogen.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pacemaker device check visit (93296) provided on March 
25, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the pacemaker device check visit. You say that the service was medically 
necessary. The Plan denied your request. The Plan says the service was provided out-of-network and was not 
approved in advance. 
  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 the pacemaker device check visit (93296) 
provided on March 25, 2022, by an out-of-network (OON) provider.