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

 
We decided that the Plan does not have to pre-approve the cataract surgery with intraocular lens (IOL) to be 
provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve the cataract surgery with IOL. You say that your surgery center is 
contracted within the enrollee's health plan. The Plan denied your request. The Plan says the cataract surgery is 
not covered. The requested provider is out-of-network, and the enrollee does not have out-of-network benefits. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The provider at issue in this case is not a network provider with the Plan. 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 cataract surgery with IOL. Our reviewer says that the service is not 
medically necessary. Our physician reviewer found the requested service is not urgent. 
 
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 cataract surgery with IOL have not been met.  
 
The Plan has network providers available who can provide the items/services at issue in this appeal. We found 
no exception that would require the Plan to pre-approve the cataract surgery with IOL. Therefore, we decided 
that the Plan does not have to pre-approve the cataract surgery with intraocular lens (IOL) to be provided by an 
out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xiidra Dro 5%. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Xiidra Dro 5%.   
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve a crutch substitute. We decided that the Plan does not have to pre-
approve a shower chair.  
 
You asked the Plan to pre-approve a crutch substitute and a shower chair. You say that the items are necessary. 
The Plan says that based on the documentation provided, coverage criteria have not been met. 
 
 We decided that the Plan has to pre-approve a crutch substitute.  
 
The Plan follows Medicare rules. Medicare rules say that medically necessary services are those that are 
reasonable and necessary for the diagnosis or treatment of an illness or injury. 
 
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 a crutch substitute. Our reviewer says 
that the services are medically necessary. Our physician reviewer found you will be non-weightbearing after 
foot surgery and require an assistive device for mobility in the home. You cannot use crutches or a manual 
wheelchair due to lack of access in your home. Given the limited options, the knee scooter can be considered 
medically appropriate and necessary for your condition. There is medical literature indicated that the knee 
scooter is a safe and well tolerated mobility aid for a patient requiring non-weight bearing after surgical 
recovery. Therefore, the requested crutch substitute or knee scooter is 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 a crutch substitute have been met. Therefore, we decided that the Plan has to 
pre-approve a crutch substitute.  
 
We also decided that the Plan does not have to pre-approve a shower chair. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided from April 20, 2023, to May 4, 
2023. 
 
You asked the Plan to pay for the dental services. You say that you could not find an in-network provider. The 
Plan denied your request. The Plan says the dental services were received from an out-of-network provider and 
are not covered by your supplemental 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. 
 
 
  The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for the dental services provided from April 20, 2023, to May 4, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for the specialist office visits, and the 
triamcinolone acetonide injection drug provided on March 22, 2023, and July 11, 2023. 
 
You asked the Plan to reduce the cost share for the specialist office visits and the injection drug. You say that 
you thought that you would only have one 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 $40 
copayment per visit, to a specialist. Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Part B drugs. 
 
You have been asked to pay a $40 copayment for each specialist office visit. These items/services fall within 
the physician/practitioner services, including doctors office visits benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan.  
 
You have also been asked to pay $0.87, which is 20% coinsurance of the allowed amount for the injection drug 
provided on March 22, 2023 ($4.36 allowed amount x 20% = $0.87). You have also been asked to pay $0.90, 
which is 20% coinsurance of the allowed amount for the injection drug provided on July 11, 2023 ($4.48 
allowed amount x 20% = $0.90). These items/services fall 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 reduce the cost share for the specialist office visits, and 
the triamcinolone acetonide injection drug provided on March 22, 2023, and July 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for an office visit provided on July 19, 2023. 
 
You asked the Plan to waive the cost share for an office visit. You say that you disagree with the cost share. 
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. Your 
contract with the Plan says that there is a $750 deductible which applies to physician/practitioner services.  
 
The item or service you asked the Plan to waive the cost share for falls within the physician/practitioner 
services benefit category. The total amount you are being asked to pay is $131.60 towards your $750 
deductible. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 
deductible which applies to physician/practitioner services. This cost sharing is a contractual obligation that 
had not been met at the time an office visit was received on July 19, 2023. Therefore, we decided that the Plan 
does not have to waive the cost share for an office visit provided on July 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided by a chiropractor on August 14, 
2023. 
 
You asked the Plan to pay for the office visit. The Plan denied your request. The Plan says an office visit is not 
a covered benefit when billed by a chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit provided by a chiropractor on August 14, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the over-the-counter (OTC) COVID-19 test (K0134) 
provided on June 27, 2023. 
 
You asked the Plan to pay for the OTC COVID-19 test. You say that you would like this service to be 
approved. The Plan denied your request. The Plan says OTC COVID-19 tests, K1034, are not covered by 
Medicare after May 11, 2023. 
 The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items, including self-
administered COVID-19 tests and the OTC COVID-19 test is an OTC item. Therefore, we decided that the 
Plan does not have to pay for the over-the-counter (OTC) COVID-19 test (K0134) provided on June 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve image guided radiation therapy (IGRT) (G6001, 77401). 
 
You asked the Plan to pre-approve IGRT. You say that IGRT is medically necessary for the enrollee. The Plan 
denied your request. The Plan says there is not enough evidence that this type of radiation therapy guidance is 
needed or effective for the enrollee's skin cancer. Therefore, it not considered standard of care. 
 
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 IGRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that usually IGRT is used when critical structures are abutting or in close proximity to the 
target that is being treated to high doses. This situation does not apply to this enrollee for which the target 
lesion can be seen on the skin to assist in daily set up. When treating skin cancers, there is generally not a need 
for IGRT unless deep structures are being treated. Certainly, using ultrasound on a daily basis is not 
unreasonable to offer but not necessary. The device itself is Food and Drug Administration (FDA) approved for 
use with ultrasound though that in and of itself does not mean that daily imaging is necessary but simply that 
the device was designed to incorporate this functionality. Therefore, to bill for daily simple simulations (77280) 
and/or IGRT for a technology for which need has not been established by published data or supported by 
consensus guidelines (many of which recommend against treatment with these devices in general) is not 
necessary. The decision is unfavorable as billing for daily IGRT which would not be furnished in accordance 
with accepted standards of medical practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IGRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve image guided radiation therapy (IGRT) (G6001, 77401).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the esophagogastroduodenoscopy provided on June 9, 2023. 
 
You asked the Plan to pay for the esophagogastroduodenoscopy. You say that the enrollee had to visit the 
emergency room because they had food stuck in their throat. The Plan denied your request. The Plan says 
Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the esophagogastroduodenoscopy provided on June 9, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that 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 care was
medically necessary. The Plan denied your request. The Plan says the 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 noted that the medical records show you were admitted to the hospital for heart
failure. Due to limited activity, you had a decline of overall strength. However, the medical records show no
documented neurologic deficit, and no complex rehabilitation needs at an IRF level of care.

The hospital therapy notes show you had poor exercise tolerance due to chronic heart failure and would not be
able to fully participate in an intensive therapy program.

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. Based
on the medical records provided, you did not meet the required criteria for IRF admission at the time of the
appeal. Therefore, we decided that the Plan does not have to provide coverage for acute inpatient rehabilitation
facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power lift recliner (E1399). 
 
You asked the Plan to pre-approve a power lift recliner. You say that the item is medically necessary. The Plan 
denied your request. The Plan says a recliner chair does not primarily serve a medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a power lift recliner (E1399).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia for upper gastrointestinal endoscopic 
procedures provided on June 9, 2023. 
 
You asked the Plan to pay for the anesthesia for upper gastrointestinal endoscopic procedures. You say that the 
enrollee had to visit the emergency room because they had food stuck in their throat. The Plan denied your 
request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.   
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the anesthesia for upper gastrointestinal endoscopic 
procedures provided on June 9, 2023.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia for the enrollee.

You asked the Plan to pre-approve Prolia. You say that at the time of the appeal, Prolia was medically
necessary. The Plan denied your request.

The Plan says the records do not show the enrollee tried and failed oral medications. Maximus overturned the
Plans denial. The Plan requested a reopen and noted that Maximus did not apply the correct criteria.

The Plan is correct in this case. In the original review, Maximus did not apply the correct step therapy criteria.
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. Based on the medical records provided, it states the enrollee cannot take the oral
alternatives to Prolia, but there is no actual medical record documentation to show the oral alternatives have
been tried and failed by the enrollee. Based on this information, we decided that Medicare rules for coverage of
Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia for the
enrollee.
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 May 13, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you did 
not know that rescue had been called. You also say that you were fine when the rescue service arrived who then 
helped you into the house. 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 May 13, 2023. 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 May 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient diagnostic tests and podiatry 
services provided on June 19, 2023, to July 12, 2023. 
 
You asked the Plan to waive the copayment for outpatient diagnostic tests and podiatry services. 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 $10 
copayment per visit and a $30 copayment per visit for outpatient diagnostic tests and podiatry services.  
 
You have been asked to pay a $10 copayment per visit for outpatient diagnostic tests and a $30 copayment per visit for podiatry services. However, since the allowed amount is less than the standard copayment, you only 
owe $5 per outpatient diagnostic test. The total amount you are being asked to pay for the diagnostic tests is 
$15 ($5 x 3 visits = $15). The total amount you are being asked to pay for podiatry services is $90 ($30 x 3 
visits = $90). The total amount you are being asked to pay is $105 ($15 + $90 =$105). This item/service falls 
within the outpatient diagnostic tests and podiatry services benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for outpatient diagnostic tests and podiatry services provided on June 19, 2023, to July 
12, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that 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 these services were medically necessary.
The Plan denied your request. The Plan says the Medicare coverage criteria were not met. Maximus overturned
the Plans denial. The Plan requested a reopen and noted that Maximus did not apply the correct criteria. The
Plan notes the medical records show you did not have a medical condition that required a physician with
special training or experience in the field of rehabilitation. There were no acute medical issues were identified
in the medical records that showed the need for an IRF level of care.

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.
Based on the medical records provided, you did not require inpatient rehabilitation at an IRF level of care.
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.