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

 
We decided that the Plan does not have to waive the coinsurance for chemotherapy drug injection and the 
associated administration services provided on April 04, 2023. 
 
You asked the Plan to waive the coinsurance for chemotherapy drug injection and the associated administration 
services. You say that you are requesting to be reimbursed for the coinsurance already paid. 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 chemotherapy drug injection and the associated 
administration services. 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 
$762.47, which is 20% of the allowed amount for chemotherapy drugs and the associated administration 
($3,812.37 allowed x 20% = $762.47). Therefore, we decided that the Plan does not have to waive the 
coinsurance for chemotherapy drug injection and the associated administration services provided on April 04, 
2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Kerecis Omage3 (Q4158). 
 
You asked the Plan to pre-approve Kerecis Omage3. 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 Kerecis Omage3. 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 for treatment of a chronic wound from 
squamous cell carcinoma and is thus 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 Kerecis Omage3 have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Kerecis Omage3 (Q4158).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics (L3000).  
 
You asked the Plan to pre-approve the foot orthotics. You say that the items should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says this item is not a covered benefit. The record 
indicates that you aren't diagnosed with diabetes, have no diabetic foot ulcers, and dont have a leg brace. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
 
  Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics (L3000).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for denosumab injection provided on March 
01, 2023. 
 
You asked the Plan to waive the coinsurance for denosumab injection. You say that you disagree with the cost 
share applied. 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 $287.28, which is 20% of the allowed amount for Medicare 
Part B drugs ($1,436.40 allowed x 20% = $287.28). Therefore, we decided that the Plan does not have to waive 
the coinsurance for denosumab injection provided on March 01, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). You asked the Plan to pre-approve the CGM. You say that the requested CGM is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the Medicare criteria was not met. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the CGM. Our reviewer says that the 
CGM coverage criteria was not met. Our physician reviewer found that the enrollee is not on insulin and does 
not have a history of problematic hypoglycemia with documentation of at least 1 of the following: recurrent 
level 2 hypoglycemic events that persist despite multiple attempts to adjust medication(s) and/or modify the 
diabetes treatment plan; or a history of 1 level 3 hypoglycemic event characterized by altered mental and/or 
physical state requiring third-party assistance for treatment of hypoglycemia. 
 
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 CGM have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a CPAP device and the supplies provided 
on February 22, 2023. 
 
You asked the Plan to waive the coinsurance for a CPAP device and the supplies. You say that you were told 
you would 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 20% 
coinsurance for durable medical equipment and related supplies.  
 
 
 You have been asked to pay 20% coinsurance of the allowed amount for a CPAP device and the supplies. This 
item/service falls within the durable medical equipment and related supplies benefit category.  
 
Date of Service Item Allowed Amount 20% Coinsurance 
February 22, 2023 CPAP device 
$748.21 $149.64 
February 22, 2023 
Humidifier $228.52 $45.70 
February 22, 2023 
Tubing $55.78 $11.16 
February 22, 2023 
Nasal interface $92.00 $18.40 
February 22, 2023 
Headgear $28.21 $5.64 
 
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 coinsurance for a CPAP device and the supplies provided on February 22, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve maxillary partial denture - cast metal framework with 
resin denture bases (including retentive/clasping materials, rests and teeth) (D5213) and mandibular partial 
denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) 
(D5214). 
 
You asked the Plan to pre-approve the dental services. You say that your dentures were damaged in an 
accident, so you need new ones. The Plan denied your request. The Plan says your benefit for the requested 
item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. This benefit includes the 
requested D5213 and D5214, but each is limited to once per 60 months 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows you received covered D5213 and D5214 on date of service July 13, 2022. Therefore, this benefit has 
been exhausted. Therefore, we decided that the Plan does not have to pre-approve maxillary partial denture - 
cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) (D5213) 
and mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping 
materials, rests and teeth) (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup services and the treatment of a root canal 
obstruction (D2950, D3331). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says your benefit for the core buildup services 
has already been exhausted. Coverage for the treatment of a root canal obstruction denied correctly as it does 
not fall within your dental 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. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. Coverage for 
the treatment of a root canal obstruction denied correctly as it does not fall within your dental benefits. 
Additionally, the record shows your benefit for core buildup services was exhausted on date of service 
February 24, 2022, and March 31, 2022. Therefore, we decided that the Plan does not have to pre-approve core 
buildup services and the treatment of a root canal obstruction (D2950, D3331).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for adding a clasp to exiting partial denture (D5660) for tooth 
#26 provided on April 3, 2023. 
 
You asked the Plan to pay for the dental service. You say that you had a tooth pulled so it was necessary to add 
a tooth and a clasp. The Plan denied your request. The Plan says your benefit for the requested item or service 
has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the Plan paid for adding a tooth to existing partial denture (D6050) for tooth #27 on April 3, 2023; 
therefore, your benefit for the requested item or service was exhausted on the date of service of April 3, 2023. 
Therefore, we decided that the Plan does not have to pay for adding a clasp to exiting partial denture (D5660) 
for tooth #26 provided on April 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the biologic materials (D3431) for tooth #12. 
 
You asked the Plan to pre-approve the dental service. You say that the provider cannot do the root canal 
without the medication. The Plan denied your request. The Plan says the denial of authorization for this service 
is correct, because the biologic materials are not covered by the 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 item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
biologic materials (D3431) for tooth #12.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone replacement graft (D7953) and surgical placement 
of implant body (D6010). 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. The Plan denied 
your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the surgical placement of implant body was exhausted. A bone replacement graft is not 
a covered benefit. Therefore, we decided that the Plan does not have to pre-approve bone replacement graft (D7953) and surgical placement of implant body (D6010).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that admission to a SNF is medically necessary. The 
Plan denied your request. The Plan says admission to a SNF does not meet criteria. 
 
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 clinical documentation shows that the enrollee has had functional and clinical status 
change thus the enrollee would be expected to require continued assessment by skilled therapy and skilled 
nursing. Documentation shows that the enrollee is on medical doctor (MD) hold from skilled therapy thus 
would not be expected to require daily skilled therapy. The enrollee is being transferred to the intensive care 
unit (ICU) thus would be expected to require daily skilled nursing. From a practical standpoint, clinical 
documentation does not support daily skilled services on an inpatient basis in a skilled nursing facility as the 
enrollee is not medically stable for this setting 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a female external urinary collection device (A4328). 
 
You asked the Plan to pay for a female external urinary collection device. You say that the item is medically 
necessary. The Plan denied your request. The Plan says this item was obtained through a provider that is not 
enrolled in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for a female external urinary collection 
device (A4328).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the new patient office visit to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve the office visit. You say that you would like to see this out-of-network 
provider. The Plan denied your request. The Plan says you must receive your care from a network provider. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the item/service at issue in this appeal. We found no exception that would require 
the Plan to pre-approve this item/service. Therefore, we decided that the Plan does not have to pre-approve the 
new patient office visit to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for an eye refraction and an unlisted special service 
(99199) provided from August 16, 2022, to December 19, 2022. 
 
You asked the Plan to reimburse for an eye refraction and an unlisted special service (99199). You say that you 
have been charged two separate amounts for items and services you could not understand. The Plan denied 
your request. The Plan says these services are not covered by your plan. 
 
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 they are a part of a routine eye examination. 
 
We looked at the file and the Plan's rules. The Plan rules say that they cover one routine eye refraction per year. 
The Plan rules also say that eye refractions outside of the annual non-Medicare-covered routine eye exams are 
not covered. An unlisted special service (99199) is excluded from this benefit. Based on this information, we 
decided that the Plan's rules for coverage of an eye refraction and an unlisted special service (99199) have not 
been met. Therefore, we decided that the Plan does not have to reimburse for an eye refraction and an unlisted 
special service (99199) provided from August 16, 2022, to December 19, 2022.  
 
Maximus read your letter and knows that you may have a quality of care concern. Maximus cannot address 
quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement 
Organization for further review.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee meets full medical and functional 
criteria to qualify for an inpatient acute rehabilitation stay and only this level of care can ensure maximal gain 
following their discharge from their inpatient acute hospitalization. The Plan denied your request. The Plan 
says an IRF admission is not medically necessary.  
 
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 that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that  the enrollee meets the requirements for an IRF 
admission. You would like reconsideration based on the records submitted. The Plan denied your request. The 
Plan says admission to an IRF is not medically necessary.  
 
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 that the enrollee does not have intensive or complex rehabilitation needs. The IRF 
admission is 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve the injection. You say that you are not able to walk by yourself and was told 
that your spine is swollen. You say that the epidural is supposed to help you move your legs so you can walk. 
The Plan denied your request. The Plan says an epidural steroid 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 pre-approve the injection. Our reviewer says that 
that you do not meet the coverage criteria. Our physician reviewer found that the epidural steroid injection that 
was provided on June 15, 2023, had provided some pain relief. However, the follow up visit on July 13, 2023, 
states you still had increased pain. Therefore, the review has determined that you do not meet the coverage 
criteria for the requested epidural steroid injection. 
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an epidural steroid injection.