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

 
We decided that the Plan does not have to waive the copayment for a colonoscopy provided on July 06, 2022. 
 
You asked the Plan to waive the copayment for a colonoscopy. You say that your friend appealed the same 
service copayment and didnt have to pay. You say that you had the same service so you are appealing 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 $300 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers. 
 
You have been asked to pay a $300 copayment for a colonoscopy. This item/service falls 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 a colonoscopy provided on July 06, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a medical eye examination (92014) or the 
coinsurance for a triamcinolone injection (J3300) provided on June 6, 2022. 
 
  You asked the Plan to waive the copayment for a medical eye examination (92014) and the coinsurance for  
triamcinolone injection (J3300). You say that you told the provider that you did not want any treatment because 
you did not know if it would be covered. You also say that the provider did not listen to you and even told you 
not to worry that it would be covered under your insurance. 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 $35 
copayment for Medicare-covered exams to diagnose and treat diseases and conditions of the eye, including an 
annual glaucoma screening for people at risk. Your contract with the Plan also clearly says that you must pay 
20% coinsurance for Medicare Covered Part B chemotherapy drugs and other Part B drugs. 
 
You have been asked to pay a $35 copayment for a medical eye examination (92014). A medical eye 
examination (92014) falls within the Medicare-covered exams to diagnose and treat diseases and conditions of 
the eye, including an annual glaucoma screening for people at risk benefit category. You have also been asked 
to pay $31.20 which is 20% of the allowed amount for a triamcinolone injection (J3300) ($156 allowed amount 
x 20% coinsurance = $31.20). A triamcinolone injection (J3300) falls within the Medicare Covered Part B 
chemotherapy drugs and other Part B 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 copayment 
for a medical eye examination (92014) and triamcinolone injection (J3300) provided on June 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core build up (D2950), pontic (D6245), and retainer 
crown (D6752) for tooth # 31 provided on July 19, 2022. 
 
You asked the Plan to pay for the dental services. You say that these services were previously approved by the 
plan. You say that you received a bill for $1,141.07 out of pocket. You also say that you would not have had 
this work done if you had known you would get this bill. The Plan denied your request. The Plan says your 
maximum annual benefit for the dental services has 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 maximum annual benefit for the dental services was exhausted on date of service July 19, 2022. 
The record shows that the Plan paid $23 for dental services received on April 28, 2022, $50.07 for dental 
services received on April 28, 2022, and $2,926.93 for dental services received on July 19, 2022. $23 + $50.07 + $2,926.93 = $3,000. Therefore, we decided that the Plan does not have to pay for the core build up (D2950), 
pontic (D6245), and retainer crown (D6752) for tooth # 31 provided on July 19, 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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 you were admitted for bilateral knee replacement. Medical problems are stable. There 
are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including 
either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the 
medical record supports a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is 
not a reasonable expectation that you will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
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: Favorable

 
We decided that the Plan has to pay for the SelectMDx testing provided on April 26, 2022. 
 
You asked the Plan to pay for the testing services. You say that the testing distinguishes those at increased risk 
for prostate cancer. The Plan denied your request. The Plan says that there was no documented result of a prior 
prostate biopsy. 
 
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. 
 
We looked at the file and the rules. The Plan used guidelines from the Local Coverage Determination for a 
ConfirmMDx testing, L36327. This coverage criteria is not binding as the rule is for a different test than what 
is at issue in this case. The Plan has not made reasonable and diligent efforts to gather and forward to us 
information regarding their decision to deny your request.  Therefore, we decided that the Plan has to pay for 
the SelectMDx testing provided on April 26, 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 pre-approve Accu-Chek Aviva Plus Strips (CPT code A4253).  
You asked the Plan to pre-approve the non-preferred items. You say that the non-preferred items are necessary. 
The Plan denied your request. The Plan says you must try and fail all preferred blood glucose testing products 
that are covered by your Medicare Advantage plan. The Plan states you may not have to try these products if 
your prescriber provides information that shows why the preferred products are not right for you. 
 
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 non-preferred items. Our physician 
reviewer found provided records do not document that you have tried and failed the Health Plan's preferred 
blood glucose testing supplies or that the Health Plan's preferred blood glucose testing supplies would be less 
effective and/or likely have adverse effects for you. 
 
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 non-preferred items have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Accu-Chek Aviva Plus Strips (CPT code A4253).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF)
admission and services.
You asked the Plan to provide coverage for IRF care. You say that at the time of the appeal IRF admission was
medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria were not met.
Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the
correct criteria.
The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that IRF admission is
covered only when it is medically reasonable and necessary as described in the Medicare rules section.
The medical records show you had edema, increasing effusion as well as new onset of facial dropping. There
was a concern for proximal left vertebral artery stenosis and basilar artery hypoplasia/stenosis.
Based on the medical records provided, your medical condition was not as such that treatment in an IRF facility
was appropriate at that time. Medicare rules for coverage of IRF care have not been met. Therefore, we decided
that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF) admission and
services.
Appeal type: 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 needs LTACH care. The 
Plan denied your request. The Plan says based on Medicare guidelines, the requested LTACH services do not 
meet the requirements for approval. 
 
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 the enrollee appears to be improving and should only require short-term 
additional acute care hospital services that can safely be provided at the current facility until more appropriate 
for a lower level of care. The enrollee does not require services at the LTACH that are not already available at 
the current facility. Transfer to the LTACH is not medically necessary as it would not be clinically 
advantageous at this time. Completion of treatment at the current facility is recommended.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve maxillary partial denture identified with code D5211. We decided 
that the Plan does not have to pre-approve problem focused re-evaluation identified with code D0170.  
 
You asked the Plan to pre-approve maxillary partial denture identified with code D5211 and problem focused 
re-evaluation identified with code D0170. You say that you disagree with the Plan's denial. The Plan says that 
the requested problem focused re-evaluation is not a covered benefit. The Plan also says that you have 
exceeded your benefit limit for dentures. 
 
We decided that the Plan has to pre-approve maxillary partial denture identified with code D5211.  
 
The Plan follows 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 file shows that you the Plan states that you have exceeded your benefit limit for this service. However, the 
documentation failed to include the date of service you previously received dentures. This means that the Plan 
did not substantiate their denial. Therefore, we decided that the Plan has to pre-approve maxillary partial 
denture identified with code D5211.  
 
We also decided that the Plan does not have to pre-approve problem focused re-evaluation identified 
with code D0170. 
 
The Plan follows Medicare rules. 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 problem focused re-
evaluation is not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pre-approve problem focused re-evaluation identified with code D0170. 
 
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: Transportation
Decision: Unfavorable

We decided the Plan does not have to pay for ambulance response provided to the enrollee on January 4, 2022.
You asked the Plan to pay for this claim as billed. You say that this claim should be paid. The Plan denied your
request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial for a
lack of claim in formation in the case file. The Plan requested a reopen and provided the required claim
information.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare requires specific codes to be
billed if the enrollee passed prior to transport. In this case it was reported that the enrollee was pronounced
dead after the ambulance call. The claim submitted has the inappropriate codes reported. The Medicare billing
criteria are not met. Therefore, we decided that the Plan does not have to pay for ambulance response provided
to the enrollee on January 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services (98940, 97014, A9270) provided on 
January 20, 2022, to June 28, 2022, by an out-of-network provider. 
 
You asked the Plan to pay for the chiropractic services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the services at issue are non-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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the services at issue in this appeal. The Plan did not pre-approve the service 
at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided 
that the Plan does not have to pay for chiropractic services (98940, 97014, A9270) provided on January 20, 
2022, to June 28, 2022, by an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-share for the outpatient surgery provided on
December 10, 2018.
You asked the Plan to waive the cost-share for the outpatient surgery. You say that this is an old charge, and
that if you had known at the time that the charge would be that high, that you would have looked at other
options. 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-covered outpatient hospital facility visit.
You have been asked to pay a 20% coinsurance for the outpatient surgery. This item/service falls within the
Medicare-covered outpatient hospital facility visit received from an out-of-network provider benefit category.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that
the Plan does not have to waive the cost-share for the outpatient surgery provided on December 10, 2018.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive cardiovascular hereditary panel and a 
comprehensive pharmacogenomic (PGx) panel. 
 
You asked the Plan to pay for two comprehensive genetic testing panels. You say that these services were 
medically necessary and were ordered by the enrollee's physician. The Plan denied your request. The Plan says 
these tests were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 pay for two comprehensive genetic testing panels. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found that the enrollee did not clearly meet criteria for coverage of these 
tests. There was no condition for which genetic testing would directly change the diagnosis or treatment. There 
was no description of the intended changes in medications or other treatment based on the results of these 
genetic tests, and there was no documented mention of expected gene-drug interactions intended to be avoided 
by this testing.  
 
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 comprehensive genetic testing panels have not been met. Therefore, we 
decided that the Plan does not have to pay for the comprehensive cardiovascular hereditary panel and a 
comprehensive pharmacogenomic (PGx) panel.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac (SI) joint injection. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has chronic low back pain. 
She had radiofrequency ablation (RFA) of the lumbar spine but the pain increased. She has tried ice, heat, 
home exercises, and gabapentin. She had an SI joint injection that relieved her pain when lying down but the 
pain returned when erect. The documentation does not quantify the degree of pain relief. It does not appear that 
the prior SI injection improved her ability to complete activities of daily living. The services are therefore not 
reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a sacroiliac (SI) joint injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection (ESI). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that repeat ESI is covered when specific criteria are 
met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a history of spinal 
stenosis with neurogenic claudication with low back pain. He has been receiving ESIs since the end of 2020. 
He received five ESIs from February 16, 2022, to October 5, 2022. The requested repeat ESI exceeds the 
utilization criteria. The risk of steroid complication is increased significantly with more than four injections in a 
12 month period. The services are not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an epidural steroid injection (ESI).