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

 
We decided that the Plan does not have to waive the copayment for the emergency room services provided on 
March 11, 2023. 
 
You asked the Plan to waive the copayment for the emergency room services. You say that you are contesting 
the emergency room cost due to inappropriate care given to you. 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 the emergency room services. 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 the emergency room 
services provided on March 11, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an air purifier. 
 
You asked the Plan to pre-approve air purifier. You say that you need this because you are severely allergic to 
dust and dust mites. The Plan denied your request. The Plan says this item is not primarily medical in nature 
and is not covered by Medicare. 
 
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 an air purifier.
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 you need a facility that specializes in 
wound care. You say your doctors are aware of the seriousness of your medical condition and are seeking the 
best possible care for you. The Plan denied your request. The Plan says the request is not medically necessary. 
 
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 you have ongoing medical issues and still require acute care services. You 
continue to receive acute care services and these have not been denied. The medical record does not indicate 
that you require services that you are not currently receiving but that would be available at the LTACH facility. 
The elements of the coverage rules are not satisfied and the requested service cannot be 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: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on July 20, 2023. 
 
You asked the Plan to pay for the office visit. You say that you are requesting reconsideration for the service 
provided. 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 office visit provided 
on July 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  the third level lumbar facet joint injection provided on April 
19, 2023. 
 
You asked the Plan to pay for  the third level injection. You say that you were told to submit the complete 
medical records which supports that the services are medically necessary. The Plan denied your request. The 
Plan says the third level injection is 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 the third level injection. Our reviewer says 
that the third level injection is not medically necessary. Our physician reviewer found that the provider did not 
provide evidence of unique circumstances for a third level injection with sufficient documentation of medical 
necessity. Although two levels were approved by the Plan the enrollee does not meet the LCD coverage 
criteria. 
 
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 third level injection have not been met. Therefore, we decided that the Plan 
does not have to pay for the third level lumbar facet joint injection provided on April 19, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that you would like continued SNF care. The Plan 
denied your request. The Plan says the request for continued SNF was denied because you were not a 
MetroPlus member as of November 1, 2023. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found You do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve brachytherapy procedure. 
 
You asked the Plan to pre-approve brachytherapy procedure. You say that you are requesting reconsideration 
for the denied claim. The Plan denied your request. The Plan says the enrollee does not meet the requirements 
for approval. 
 
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 brachytherapy procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation that the electronic brachytherapy treatment for basal cell 
carcinoma, nodular type of the left mandibular angle at issue in this case meets all Medicare criteria for 
medically reasonable and necessary and safe and effective for the patient. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of brachytherapy procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve brachytherapy procedure.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve LTACH services. You say that the enrollee needs LTACH services. The 
Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care and does not 
require transfer to an LTACH. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the record indicates that the enrollee is improving but still requires acute care 
services before transitioning to a lower level of care. The enrollee continues to receive acute care services, and 
these have not been denied. The medical record does not indicate that the enrollee requires services that she is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules 
are not satisfied. The requested service cannot be 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 LTACH services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve LTACH services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the breast ultrasound provided on 
September 11, 2023. 
 
You asked the Plan to waive the copayment for the breast ultrasound. You say that the ultrasound was a 
preventive service and should be covered in full. 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 for specialty Medicare-covered outpatient diagnostic tests, including ultrasounds.  
 
 You have been asked to pay a $40 copayment for the breast ultrasound. This item/service falls within the 
outpatient diagnostic tests and therapeutic 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 the breast ultrasound provided on September 11, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cimerli. 
 You asked the Plan to pre-approve Cimerli. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says the enrollee did not meet the step therapy requirements. 
 
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 the injections. Our physician reviewer 
found that the Plan requires a trial of byooviz before they will approve Cimerli. Our physician reviewer found 
that based on the medical records provided there is no indication that the enrollee has tried and failed the 
required drug. Our physician reviewer found that there is no indication that the Plans required drug 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 Cimerli have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Cimerli.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sequence analysis gene panel liquid biopsy (CPT code 
81455) provided on April 25, 2023. 
 
You asked the Plan to pay for the sequence analysis gene panel liquid biopsy. You say that you disagree with 
the Plan's denial. The Plan denied your request. The Plan says the services rendered 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 pay for the sequence analysis gene panel liquid 
biopsy. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee has prostate cancer. Liquid biopsies have 
recently emerged as a promising method of detecting biomarkers in lung cancer patients without the need to conduct invasive procedures. New approaches for biomarker discovery have emerged due to advances in high-
throughput sequencing technologies and bioinformatics tools. In this review, we comprehensively describe 
established and emerging methods for identifying lung cancer biomarkers using liquid biopsy. Liquid biopsy 
has revolutionized lung cancer diagnostics and management; however, limitations and challenges remain to 
fully realize its potential. In this case, there is no specific clinical rationale for the test. Therefore, the enrollee 
did not meet criteria for the services rendered. 
 
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 sequence analysis gene panel liquid biopsy have not been met. Therefore, 
we decided that the Plan does not have to pay for the sequence analysis gene panel liquid biopsy (CPT code 
81455) provided on April 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the saline infusion provided on July 12, 
2023. 
 
You asked the Plan to waive the copayment for the saline infusion. You say that you should not have to pay. 
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 $15 
copayment for Medicare Part B prescription drugs. 
 
You have been asked to pay a $15 copayment for the saline infusion. 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. However, since the allowed amount is less than the standard copayment, you 
only owe $2.00. Therefore, we decided that the Plan does not have to waive the copayment for the saline 
infusion provided on July 12, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 standard power wheelchair with multiple 
power option (K0861) and combination tilt and recline power seating system (E1007). 
 
You asked the Plan to pre-approve a Group 3 standard power wheelchair and combination tilt and recline 
power seating system. The Plan denied your request. The Plan says the enrollee does not have medical need for 
multiple power options included with a K0861 Group 3 power wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair (PWC) with multiple 
power options (such as code K0861) is covered if the criteria listed in the Medicare rules section of this letter 
are met. Medicare rules also say that if the PWC base is not covered, then related accessories will be denied. 
 
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 Group 3 standard power wheelchair 
and combination tilt and recline power seating system. Our reviewer says that the criteria for coverage have not 
been met. Our physician reviewer found the enrollee has inclusion myositis and chronic functional impairment. 
The enrollee is able to stand and has intact skin. Our reviewer also found that the enrollee does not have high 
risk for skin breakdown, use a catheter intermittently, have spasticity or require an alternative means of 
managing power drive. 
 
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 Group 3 standard power wheelchair and combination tilt and recline power 
seating system have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 3 
standard power wheelchair with multiple power option (K0861) and combination tilt and recline power seating 
system (E1007).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve block injections.  
 
You asked the Plan to pre-approve genicular nerve block injections. You say that genicular nerve block 
injections are medically necessary. The Plan denied your request. The Plan says genicular nerve block 
injections are experimental/investigational. 
 
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 genicular nerve block injections. Our 
reviewer says that the requested genicular nerve block injections are not considered medically reasonable and 
necessary. Our physician reviewer found this is considered experimental therapy and is the subject of ongoing 
clinical trials. Therefore, the request is deemed not medically reasonable and 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 genicular nerve block injections have not been met. Therefore, we decided that 
the Plan does not have to pre-approve genicular nerve block injections.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for the radiation therapy treatment provided 
from April 5, 2023, to April 11, 2023. 
 
You asked the Plan to reduce the coinsurance for the radiation therapy. You say that you are concerned with 
the patient responsibility in comparison to previous years. 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 in-network Medicare-covered therapeutic radiological services and supplies, including 
radiation therapy. 
 You have been asked to pay up to 20% coinsurance of the allowed amount for the radiation therapy treatment. 
These services fall within the outpatient diagnostic tests and therapeutic 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 reduce the coinsurance for the radiation therapy treatment provided from April 5, 2023, to 
April 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for allergy testing (95165) provided to the enrollee on February
9, 2023, by Provider A and Provider B.

You asked the Plan to pay this claim. The Plan denied your request. The Plan says the records provided do not
support the services billed. Maximus overturned the Plans denial. The Plan requested a reopen and stated that
Maximus did not apply the correct billing criteria. The Plan noted that the allergy vials were prepared by
Provider A, which no documentation of qualifications, training, credentials, or an associated National Provider
Identifier (NPI) number. The Plan states the clinical record does not show that the provider identified on the
claim (Provider B) as the "rendering provider" personally rendered any service or documentation. There is no
documentation of direct supervision by the physician.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that the provider,
supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to
determine whether payment is due and the amount of payment. We looked at the file and Medicare rules. Based
on this information, we decided that there is insufficient information in the record to determine if Medicare
rules for coverage of this claim as billed have been met. The rendering providers listed cannot be verified.
Therefore, we decided that the Plan does not have to pay for allergy testing (95165) provided to the enrollee on
February 9, 2023.