Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone graft (D6104) for tooth number 14 and 30. 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says this service is not a covered benefit under the enrollee's 
dental policy. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a bone graft 
(D6104) for tooth number 14 and 30.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical laparoscopy with suspension of vaginal apex 
(57425). 
 
You asked the Plan to pre-approve surgical laparoscopy with suspension of vaginal apex. You say that this 
service is medically necessary to treat the enrollee's condition. The Plan denied your request. The Plan says the 
clinical information does not support the procedure in question. 
 
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 surgical laparoscopy with suspension of 
vaginal apex. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found there is insufficient clinical documentation to support this 
surgery. There is no documentation in the annual exam nor in the consult that the patient is having any 
symptoms related to the bladder prolapse/cystocele that require treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of surgical laparoscopy with suspension of vaginal apex have not been met. 
Therefore, we decided that the Plan does not have to pre-approve surgical laparoscopy with suspension of 
vaginal apex (57425).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lung cancer screening with low dose computed 
tomography (LDCT). 
 
You asked the Plan to pre-approve a lung cancer screening with LDCT. 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 lung cancer screening with LDCT is covered when 
specific criteria is met. 
 
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 lung cancer screening with LDCT. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee is 
asymptomatic and is in the appropriate age group for LDCT, however the remainder of the criteria, in particular 
the duration and pack year history do not meet the CMS requirements for LDCT. 
 
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 lung cancer screening with LDCT have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a lung cancer screening with low dose computed tomography 
(LDCT).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomography colonography (74263). 
 
You asked the Plan to pre-approve a computed tomography colonography. You say that the enrollee cannot 
have a regular colonoscopy, as he has a history of aortic valve prosthesis. The Plan denied your request. The 
Plan says the requested study is for screening purposes and the enrollee does not have any signs or symptoms 
of disease. 
 
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 a computed tomography colonography. 
Our reviewer says that a computed tomography colonography is not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee has a history of colon adenoma. The 
enrollee's physical exam and history were unremarkable. The records show that a colon cancer screening 
discussed. The enrollee has an artificial valve, making a colonoscopy higher risk for him, as he is on warfarin 
therapy. Cologuard not indicated due to history of colon adenoma. Therefore, a request for CT colonography 
was made. The documentation did not describe an absolute contraindication to standard colonoscopy. 
Anticoagulation was the main indication for virtual colonoscopy, however, there was no indication a short 
cessation of warfarin for the standard colonoscopy would be unreasonable or contraindicated for the enrollee. 
Therefore, without sufficient support made for this request, the CT colonography will be considered 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 a computed tomography colonography have not been met. Therefore, we 
decided that the Plan does not have to pre-approve computed tomography colonography (74263).
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 the records provided support the need for care in an 
IRF. The Plan denied your request. The Plan says the enrollee's condition is not medically complex. The Plan 
says that the enrollee cannot be reasonably expected to participate in three hours of therapy per day. The Plan 
says that the enrollee does not need a coordinated program of care through team conferencing. The Plan says 
that the enrollee's needs can safely be met at a less intensive level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 patient was 
admitted for congestive heart failure and a urinary tract infection. The enrollee's medical conditions are stable. 
There are no medical needs requiring inpatient admission. 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 documents a 
need for physical and occupational therapy, it does not document a need for an intensive rehabilitation 
program. There is not a reasonable expectation that the enrollee 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to provide facet injections. 
 
You asked the Plan to provide Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) 
joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level 
(64493) and second level (64494). You say that the enrollee needs the injections for pain relief. The Plan 
denied your request. The Plan says the injections are not supported in the records. 
 
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 provide Injection(s), diagnostic or therapeutic agent, 
paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or 
CT), lumbar or sacral; single level (64493) and second level (64494). Our reviewer says that the requested 
services are not considered medically reasonable and necessary in this case. Our physician reviewer found 
there are clear alternate pain generators here. There is no documentation of a surgical consult. The request does 
not meet the criteria of the LCD and is not medically reasonable or 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 Injection(s), diagnostic or therapeutic agent, paravertebral facet 
(zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or 
sacral; single level (64493) first level and second level (64494) have not been met. Therefore, we decided that 
the Plan does not have to provide facet injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bone replacement graft. 
 
You asked the Plan to pre-approve the requested service. The Plan denied your request. The Plan says the 
requested service is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Although the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a bone 
replacement graft.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair (PWC) and accessories. 
 
You asked the Plan to pre-approve a PWC and accessories. You say that the items 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 if any power operated vehicle (POV) or PWC is only 
for use outside the home, it will be denied as non-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 a PWC and accessories. Our reviewer 
says that the items are not medically necessary. Our physician reviewer found according to Medicare a power 
mobility device is medically necessary if a beneficiary has a mobility limitation that significantly impairs 
his/her ability to participate in one or more mobility-related activities of daily living. The mobility limitation 
cannot be sufficiently and safely resolved by the use of a fitted cane or walker or the beneficiary does not have 
sufficient upper extremity function to self-propel an optimally-configured manual wheelchair. Additionally, if 
any POV or PWC is only for use outside the home, it is denied as non-covered. In this case, you requested the 
power wheelchair for community only use. You are able to safely ambulate household distances with a walker. 
 
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 PWC and accessories have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a power wheelchair (PWC) and accessories.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ranolazine 1000mg tablets. 
 
You asked the Plan to pre-approve the ranolazine tablets. You say that the enrollee is stable on this medication. 
The Plan denied your request. The Plan says this oral drug can only be covered by Medicare Part D. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve ranolazine 1000mg tablets.  
 
Benefits for the ranolazine tablets may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IGH@ genetic testing. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that IGH@ testing is covered for acute lymphoblastic 
leukemia (ALL) and lymphoma, B-cell to guide therapeutic decision making. 
 
We looked at the file and Medicare rules. The file shows that the IGH@ testing is being requested for a 
diagnosis of thrombocythemia. This diagnosis is not one for which Medicare covers this testing. Therefore, we 
decided that the Plan does not have to pre-approve IGH@ genetic testing.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) of the neck. 
 
You asked the Plan to pre-approve the CT scan. You say that the records provided support the need for the 
requested CT scan. The Plan denied your request. The Plan says the requested CT scan is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 the CT scan. Our reviewer says that the 
requested CT scan is not medically necessary. Our physician reviewer found the enrollee has had localized 
swelling and a mass/lump on her neck above her clavicle bilaterally for two and a half weeks which started 
with a rash and pimple-like bumps which had gone away. There was no lymphadenopathy or rash noted on 
examination, however, a prominent soft tissue area noted superficial to the clavicle. The mass was soft and 
preceded by a rash which should warrant observation and/or workup for other causes prior to a CT scan to rule 
out malignancy. The records did not show sufficient support for CT at this time. 
 
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 CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve computed tomography (CT) of the neck.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neuropsychological testing services to be provided by 
an out of network (OON) provider. 
 
You asked the Plan to pre-approve the OON neuropsychological testing. You say that you feel that this testing 
is needed, and there are no network providers willing to accept the enrollee at this time. As such, you would 
like approval to be seen out of network. The Plan denied your request. The Plan says after additional evaluation 
with the enrollee's treating providers, a new referral was submitted, and approval has been granted to be 
evaluated by a neuropsychological provider in the plan's network. Since this is available within the network, 
OON care is not required. 
 
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 confirmed that there 
are network providers available who can provide the items/services at issue in this appeal, and approval was 
granted to see this network provider. We found no exception that would require the Plan to pre-approve these 
items/services. Therefore, we decided that the Plan does not have to pre-approve neuropsychological testing 
services to be provided by an out of network (OON) provider.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve continued Prolia injections (J0897) beyond June 30, 2021. 
 
You asked the Plan to pre-approve the Prolia injections. You say that the enrollee has been on Prolia, 60mg, 1 
injection every 6 months since 2014. You say that the enrollee has been showing improvement with the 
injection every 6 months since December 2014. The Plan denied your request. The Plan says that there is no 
evidence that the enrollee has osteoporosis. The Plan also says that the Prolia injections for treatment of 
osteopenia are not medically reasonable or necessary. 
 
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 the Prolia injections. Our reviewer says 
that continued Prolia injections are medically necessary. Our physician reviewer found Prolia is not FDA-
approved for treatment of osteopenia. The reviewer found that the provided medical records and a citation in 
Drugdex, there is documentation that Prolia has been shown to improve bone mineral density (BMD) from 
baseline compared with placebo in a randomized study in postmenopausal women with low BMD. The 
reviewer found that the records indicate that you have low bone mineral density. The reviewer also found that 
you are taking supplemental calcium and multiple vitamins. Therefore, the reviewer found that the requested 
continuation of Prolia injections are 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 the Prolia injections have been met. Therefore, we decided that the Plan has to 
pre-approve continued Prolia injections (J0897) beyond June 30, 2021.  
 
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: Lab
Decision: Favorable

We decided the Plan does not have to pay for laboratory services provided to the enrollee on June 16, 2020.
You asked the Plan to pay for laboratory services provided on June 16, 2020. You say that this claim should be paid. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional claim information. The Plan says that this claim was billed with an inappropriate POS code. The Plan provided a copy of the claim to show the claims billed.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, this claim cannot be paid due to an error with the POS code billed. Medicare billing criteria were not met. Therefore, we decided that the Plan does not have to pay for laboratory services provided to the enrollee on June 16, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cardiac positron emission tomography (PET) scan for 
the enrollee. 
 
You asked the Plan to pre-approve this service. You say that this imaging is medically necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. 
 
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 this service. 
Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. 
Our physician reviewer found based on the records the patient had dyspnea documented to be due to a 
combination of significant anemia requiring transfusions and hypertensive heart disease.  There are no 
documented symptoms or findings concerning for coronary ischemia such as chest pain, electrocardiographic 
changes, troponin elevation, or LV systolic dysfunction on echocardiography.  Therefore, the documentation 
does not support the medical necessity for cardiac PET scanning because the records show no documented 
"known or suspected coronary artery disease". We looked at this physician's review, the file, and Medicare 
rules. Based on this information, we decided that Medicare rules for coverage of this service have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a cardiac positron emission tomography 
(PET) scan for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services (D7140, D6111, D5751) for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says these are not covered services. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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 pre-approve 
dental services (D7140, D6111, D5751) for the enrollee.