Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Kerecis Omega3 skin substitute. 
 
You asked the Plan to pre-approve Kerecis Omega3. You say that the enrollee's wound responded better to a 
sample of Kerecis Omega3 than to any other treatments. The Plan denied your request. The Plan says that the 
enrollee does not meet the requirements for skin substitution. 
 
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 Kerecis Omega3. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found Kerecis Omega3 is not standard 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 Kerecis Omega3 have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Kerecis Omega3 skin substitute.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox, 200 units.  
 
You asked the Plan to pre-approve Botox, 200 units. You say that you are requesting an increase of the 
requested drug to 200 units as 100 units did not last long enough. The Plan denied your request. The Plan says 
the requested dosage has not been determined by the FDA to be effective for the enrollee's condition. There are 
not enough medical studies found in Medicare approved medical journals to show this dosage of medicine 
improves the health of patients with the enrollee's medical condition. There are not enough medical studies 
found in Medicare approved medical journals to show this dosage of medicine will help in the enrollee's care. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Botox, 200 units. Our reviewer says 
that the requested drug is not medically necessary. Our physician reviewer found Based on the medical records provided and the Medicare-approved major drug compendia there is no documentation that the Botox at a dose 
of 200 units for treatment of overactive bladder meets all Medicare criteria for medically reasonable and 
necessary for the enrollee. Based on the medical records provided and the Medicare-approved major drug 
compendia there is no documentation that the Botox at a dose of 200 units for treatment of overactive bladder 
meets all Medicare criteria for safe and effective 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 Botox, 200 units have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Botox, 200 units.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) service provided 
on September 11, 2023. 
 
You asked the Plan to waive the copayment for an emergency room (ER) service. You say that you should not 
owe this 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 $110 
copayment for emergency room services. 
 
You have been asked to pay a $110 copayment for an emergency room (ER) service. This item/service falls 
within the emergency room 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 
an emergency room (ER) service provided on September 11, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-sharing for an injection of regadenoson (a Medicare 
Part B drug) and myocardial perfusion imaging provided on August 25, 2023. 
 
You asked the Plan to waive the cost-sharing for Part B drug and diagnostic imaging. You say that you were 
told this would be 100% covered. 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 20% coinsurance for Part B drug and $270 copayment for diagnostic imaging from an in-network provider. The 
allowed amount of the regadenoson is $249.12, resulting in a coinsurance amount of $49.82. Therefore, your 
total cost-sharing amount is $319.82. 
 
You have been asked to pay 20% coinsurance for Part B drug and $270 copayment for diagnostic imaging. 
These services fall within the "Medicare Part B Prescription Drugs" and "Outpatient Diagnostic Testing and 
Therapeutic Services and Supplies" benefit categories. 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-sharing for 
an injection of regadenoson (a Medicare Part B drug) and myocardial perfusion imaging provided on August 
25, 2023.  
 
Your complaint regarding receiving inaccurate information about the cost-sharing for these services is 
considered to be a grievance. Maximus Federal Services does not have the jurisdiction to address grievances. 
Please contact the Plan for more information about your grievance.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Catheter, transluminal intravascular 
lithotripsy, coronary provided on August 08, 2023. 
 
You asked the Plan to waive the coinsurance for Catheter, transluminal intravascular lithotripsy, coronary. You 
say that you had an 85% blockage, this was not a voluntary procedure, therefore, you should not have to pay 
the billed amount. 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 20% 
coinsurance for outpatient hospital services. 
 
You have been asked to pay 20% coinsurance for Catheter, transluminal intravascular lithotripsy, coronary. 
This item/service falls within the outpatient hospital 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. The total you owe is $3,265.10 ($16,325.52 
allowed amount x 20% coinsurance = $3,265.10) Therefore, we decided that the Plan does not have to waive 
the coinsurance for Catheter, transluminal intravascular lithotripsy, coronary provided on August 08, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for denosumab injection provided on 
September 14, 2022. 
 
You asked the Plan to reduce the coinsurance for denosumab injection. You say that you say that the enrollee 
has an $280 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 20% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for denosumab injection. 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. The total you owe is $534.12 ($2,670.60 allowed amount x 20% coinsurance = 
$534.12) Therefore, we decided that the Plan does not have to reduce the coinsurance for denosumab injection 
provided on September 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injections provided on August 31, 2023. 
 
You asked the Plan to pay for the injections. You say that you are requesting reconsideration. 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 the injections provided 
on August 31, 2023.
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 an IRF admission is medically necessary due to a 
decline in the enrollee's condition. The Plan denied your request. The Plan says the records do no document 
clinical complexity or existing debility that would make care at the enrollee's residence unsafe. A lower level of 
care is appropriate.  
 
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 enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical problems are stable and there are no complex nursing or rehabilitation needs. The enrollee does 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 this patient 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room visit provided on August 
31, 2023. 
 
You asked the Plan to waive the copayment for emergency room visit. You say that you cannot afford 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 $110 
copayment for emergency care. 
 
You have been asked to pay a $110 copayment for emergency room visit. This item/service falls within the 
emergency 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 emergency room visit 
provided on August 31, 2023.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve a colonoscopy (45378). 
 
You asked the Plan to pre-approve a colonoscopy. You say that this exam is necessary, as polyps were found 
during the enrollee's previous colonoscopy five years ago. The Plan denied your request. The Plan says that the 
enrollee only meets criteria for coverage of a colonoscopy once every 10 years. Given that the previous 
colonoscopy was performed in 2018, a repeat colonoscopy is not appropriate at this time. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 a colonoscopy. Our reviewer says that 
the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the records show that the enrollee had polyps found on their last colonoscopy, so a repeat 
colonoscopy five years later is medically necessary in this case. 
 
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 colonoscopy have been met. Therefore, we decided that the Plan has to pre-
approve a colonoscopy (45378).  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with ActiGraft (G0465). 
 
You asked the Plan to pre-approve ActiGraft. You say that the requested treatment is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says the requested treatment is not a covered benefit. 
 
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 ActiGraft. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee has a diabetic wound. PRP and ActiGraft both have insufficient evidence of efficacy in 
the peer-reviewed literature for treatment of this type of wound. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ActiGraft have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with ActiGraft (G0465).
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve revascularization (37227). 
 
You asked the Plan to pre-approve revascularization. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that PTA is covered when used under certain conditions. 
 
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 revascularization. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found the documentation does not meet 
coverage criteria and does not support the medical necessity of the procedure in question. The description of 
symptoms does not sufficiently demonstrate that the enrollee is experiencing lifestyle limiting walking 
limitation attributable to claudication. It is however documented that the enrollee had been using a treadmill 
until she recently fell and fractured her shoulder. There is no suggestion of limb threat. Ankle brachial indexes 
(ABIs) are essentially normal. She has a history of arthritis, but the details are not provided. The documentation does not suggest any evidence of limb threatening ischemia and does not demonstrate that the enrollee would 
experience meaningful improvement in lifestyle with intervention. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of revascularization have not been met. Therefore, we decided that the Plan does 
not have to pre-approve revascularization (37227).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care supplies (A6212) provided on June 28, 2023, 
by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the wound care supplies (A6212). You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were 
neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care. 
 
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 wound care supplies (A6212) provided on 
June 28, 2023, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 You asked the Plan to pre-approve home health services. You say that you are requesting reconsideration for 
the denied claim. The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the enrollee is 
noted to be medically stable. The enrollee has been educated regarding their medications and the enrollee have 
not recently been hospitalized. The enrollee is noted to have completed their antibiotic for bronchitis and there 
is no sign of significant infection. The enrollee does not require wound care or management of a tracheostomy 
or feeding tube. The enrollee is modified independent with mobility and the enrollees progress and level of 
function remains unchanged with ongoing physical therapy. 
 
Therefore, the continued home health skilled nursing care and physical therapy are not 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electrocardiogram provided on February 15, 2023, by an out-
of-network (OON) provider.  
 
You asked the Plan to pay for electrocardiogram. You say that this service is supported in the records. The Plan 
denied your request. The Plan says this was not authorized. 
 
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 electrocardiogram provided on February 15, 2023, 
by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bupivacaine (J3490) provided on September 21, 2023. 
 
You asked the Plan to pay for bupivacaine. You say that this drug was medically necessary and should be paid. 
The Plan denied your request. The Plan says this is a packaged service which is not paid separately. 
 
The Plan must follow Medicare rules. Medicare rules say that all services integral to accomplishing a procedure 
are considered bundled into that procedure and, therefore, are considered a component part of the 
comprehensive code.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of bupivacaine have not been met. Specifically, bupivacaine is a local anesthetic which would be 
considered integral to, and therefore included in the payment for the injection service or other procedure 
provided. Therefore, we decided that the Plan does not have to pay for bupivacaine (J3490) provided on 
September 21, 2023.