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

 
We decided that the Plan does not have to pre-approve Leqvio (inclisiran). 
 
You asked the Plan to pre-approve Leqvio. You say that the requested drug is medically necessary to treat the 
enrollee's diagnosis. The Plan denied your request. The Plan says the drug requested does not meet the 
requirements necessary for approval. 
 
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 Leqvio. Our reviewer says that the 
requested drug does not meet the criteria required to be approved. Our physician reviewer found the enrollee 
has a history of hyperlipidemia and intolerance to statins, with plans to use inclisiran as monotherapy; As such, 
the enrollee does not meet current guideline criteria for drug use. In summary, there is insufficient 
documentation to support the medical necessity for the use of inclisiran, in this enrollee's clinical management. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Leqvio have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Leqvio (inclisiran).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a laparoscopy with total hysterectomy provided on 
September 19, 2023. 
 
You asked the Plan to pay for a laparoscopy with total hysterectomy. You say that this is supported in the 
records. 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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 a laparoscopy with total hysterectomy provided on September 19, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the apicoectomy on one root of a molar (D3425), 
apicoectomy on each additional root (D3426), retrograde filling (D3430), bone replacement graft for ridge 
preservation (D7953), and deep sedation/general anesthesia (D9222) provided on June 27, 2023. 
 You asked the Plan to pay for the apicoectomies, retrograde filling, bone replacement graft, and deep 
sedation/general anesthesia. The Plan denied your request. The Plan says these services are not covered under 
your benefit plan. 
 
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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
apicoectomy on one root of a molar (D3425), apicoectomy on each additional root (D3426), retrograde filling 
(D3430), bone replacement graft for ridge preservation (D7953), and deep sedation/general anesthesia (D9222) 
provided on June 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (01992) provided on December 9, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 01992 is not supported in the medical record. Specifically, the code was not billed with 
a valid diagnosis code per LCD Reference Article: Billing and Coding Article: Monitored Anesthesia Care 
(A57361). Based on this information, we decided that Medicare rules for coverage of the lab services have not 
been met. Therefore, we decided that the Plan does not have to pay for lab services (01992) provided on 
December 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sterile gauze (A6222) sterile specialty absorptive 
dressing (A6252) sterile conforming bandage (A6446) and non-waterproof tape (A4450) provided on July 31, 
2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the wound care supplies. You say that this enrollee has been treated for their 
wounds and billing separately for these supplies is appropriate. The Plan denied your request. The Plan says 
enrollees must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before 
services being rendered. 
 
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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 sterile gauze (A6222) sterile specialty absorptive dressing (A6252) sterile conforming bandage (A6446) 
and non-waterproof tape (A4450) provided on July 31, 2023, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the at-home over-the counter COVID-19 tests (K1034)
provided May 1, 2023.

You asked the Plan to pay for the tests. You say that the claim should be paid. The Plan denied your request.
The Plan says that the claim needed to be sent to Original Medicare. Maximus overturned the Plan's denial
based on lack of information. The Plan requested a reopening and stated that this is not covered by the Plan and
needs to be submitted to Original Medicare. The Plan is correct in this case. Medicare rules say that enrollees
cannot submit a claim for these tests to Medicare or their MA plan for reimbursement under this initiative. The
participating provider would bill Medicare directly for reimbursement of the tests provided to the enrollee.
Based on this information, we decided that Medicare rules for coverage of the tests have not been met.
Therefore, we decided that the Plan does not have to pay for the at-home over-the counter COVID-19 tests
(K1034) provided May 1, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gingival irrigation with a medicinal agentper quadrant 
(D4921 x 4) provided on September 19, 2023. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services provided are not covered under 
the supplemental dental policy.  
 
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 services provided are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the gingival 
irrigation with a medicinal agentper quadrant (D4921 x 4) provided on September 19, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diabetic supplies provided on August 15, 2023. 
 
You asked the Plan to pay for diabetic supplies. You say that you have provided all of the appropriate 
documents needed for payment. The Plan denied your request. The Plan says the documentation requirements 
have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid proof of delivery. The proof of delivery provided does not have the 
enrollees signature. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for diabetic supplies 
provided on August 15, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy provided on July 
26, 2023. 
 
You asked the Plan to waive the copayment for a diagnostic colonoscopy. You say that you had this done at the 
providers order, and thought the plan would cover it 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 $325 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
You have been asked to pay a $325 copayment for a diagnostic 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 diagnostic colonoscopy 
provided on July 26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on May 02, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that this testing was medically necessary. 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 Plan had network providers available who were capable of providing the items/services at issue in this appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 laboratory services provided on May 02, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (99285) provided on August 16, 
2023. 
 
You asked the Plan to pay for the emergency room services. You say that this service was medically necessary. 
The Plan denied your request. The Plan says this service is non-covered.  
The Plan must follow Medicare rules. Medicare rules say that Medicare excludes from coverage items and 
services furnished to beneficiaries in State or local government custody. 
 
We looked at the file and Medicare rules. The patient was incarcerated at the time the service was rendered. 
Based on this information, we decided that Medicare rules for coverage of the emergency room services have 
not been met. Therefore, we decided that the Plan does not have to pay for emergency room services (99285) 
provided on August 16, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapy services (97140, 97112, 97530, 97110) provided on 
August 25, 2023. 
 
You asked the Plan to pay for the therapy services. You say that this service was medically necessary The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 97140, 97112, 97530, & 97110 are not supported in the medical record. Specifically, 
the claim was billed with a left and right diagnosis code. There is a more appropriate bilateral diagnosis code. 
Based on this information, we decided that Medicare rules for coverage of the therapy services have not been 
met. Therefore, we decided that the Plan does not have to pay for therapy services (97140, 97112, 97530, 
97110) provided on August 25, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (80307, G0482) provided on May 11, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed codes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 80307, & G0482 are not supported in the medical record. Specifically, no lab results 
were provided for this service. Based on this information, we decided that Medicare rules for coverage of the 
lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services 
(80307, G0482) provided on May 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and venipuncture. provided on January 10, 
2023. 
 
You asked the Plan to pay for an office visit and venipuncture.. You say that the services were medically 
necessary. 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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 an office visit and venipuncture. provided on January 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on August 07, 2023, to 
August 10, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that these services were medically necessary. 
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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 laboratory services provided on August 07, 2023, to August 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 31, 2023. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on July 31, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (CGM) (A4329) provided on 
August 24, 2023. 
 
You asked the Plan to pay for the CGM. You say that the items should be covered as you disagree with the 
denial. The Plan denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
 The record does not contain a valid and current physician order or relevant medical records which support 
medical necessity for the supplies provided in this case. There are no new orders documented in the medical 
records for a Continuous Glucose Monitor (CGM) device or supplies. Additionally, the records are from 
August 30, 2022, and do not indicate that the member is seen every 6 months to document adherence to their 
CGM regimen and diabetes treatment plan. The record shows that the Plan made several attempts to obtain the 
necessary documentation without success. Therefore, we decided that the Plan does not have to pay for a 
continuous glucose monitor (CGM) (A4329) provided on August 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve stereotactic body radiation therapy (SBRT). 
 
You asked the Plan to pre-approve SBRT. You say that the services are necessary. The Plan denied your 
request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been 
met. 
 
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 SBRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found when SBRT is considered medically necessary, it is standard to treat all lesions in one course. 
The radiation oncologist recommended 3 consecutive courses of SBRT which is not standard of care and does 
not follow ASTRO model policy necessitating that all disease be able to be safely treated one course. Nevertheless, the need for SBRT is not supported in the case file. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SBRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve stereotactic body radiation therapy (SBRT).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for deluxe frames (V2025), bifocal lenses (V2200), lenses 
(V2782), and anti-reflective coating (V2750) provided on September 19, 2023. 
 
You asked the Plan to pay for deluxe frames, bifocal lenses, lenses, and anti-reflective coating. You say that 
you are appealing with supporting records. The Plan denied your request. The Plan says this benefit has been 
exhausted. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when . 
 
We looked at the file and the Plan's rules. The Plan rules say that they offer a $100 benefit toward the purchase 
and fitting of eyeglasses and pair of lenses or contact lenses (1 per calendar year). You are responsible for any 
amount over $100 retail price. The record shows the benefit was exhausted with this date of service. Based on 
this information, we decided that the Plan's rules for coverage of deluxe frames, bifocal lenses, lenses, and anti-
reflective coating have not been met. Therefore, we decided that the Plan does not have to pay for deluxe 
frames (V2025), bifocal lenses (V2200), lenses (V2782), and anti-reflective coating (V2750) provided on 
September 19, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for arthrocentesis, aspiration, and/or injection provided on 
September 01, 2023. 
 
You asked the Plan to pay for arthrocentesis, aspiration, and/or injection. You say that these services were 
medically necessary. 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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 arthrocentesis, aspiration, and/or injection provided on September 01, 2023.