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

We decided that the Plan does not have to pre-approve JAK2 genetic testing for the enrollee.
You asked the Plan to pre-approve this testing for the enrollee. You say that this testing is medically necessary.
The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus partially
overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct
LCD criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for JAK2, F5 and F2
genetic testing. The Maximus Physician Reviewer determined that factor V Leiden and prothrombin gene
mutation were not medically necessary as they were unlikely to change management of the enrollee if they
were positive. The reviewer also determined that criteria for testing for polycythemia with JAK2 met coverage
criteria, given a hemoglobin greater than 16.5 and thrombosis. JAK2 was determined to be reasonable and
medically necessary.
The Plan requested a reopen and states that JAK2 exon 12 testing was not requested. Rather, JAK2 V617F
variant testing was requested. The plan states that while the enrollee had an elevated hemoglobin, the
hematocrit was normal, and that a serum erythropoietin level and a bone marrow biopsy were not performed.
The Plan notes that the LCD states that genetic testing for the V617F mutation is medically necessary when
testing impacts medical management, and when the patient would meet WHO diagnostic criteria for
polycythemia vera if JAK V617F were to be identified. The Plan further notes that an elevated hemoglobin
alone does not fulfill the WHO diagnostic criteria for polycythemia vera.
The medical records how the enrollee is a 65-year-old man with recurrent venous thromboembolism despite
anticoagulation. The oncology notes dated January 21, 2022, recommended JAK2 reflexive to evaluate for
myeloproliferative neoplasm. Our Medical Director has determined that the Plan is correct in this case.
The documentation does not support that the enrollee would meet WHO criteria for polycythemia vera if JAK2
V617F were identified. Medicare coverage criteria are not met.
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 testing have not been met. Therefore, we decided that the Plan does not
have to pre-approve JAK2 genetic testing for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMs procedure 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 the services are not 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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there remains a dearth of randomized, blinded clinical studies examining long-term clinical outcomes 
establishing the value of CardioMEMS in patient management. As a result, at this time the CardioMEMS 
system would not be considered medically appropriate and necessary in this patients 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the CardioMEMs procedure for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Administration of vaccines provided on January 3, 2022 by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for Administration of vaccines. You say that you would like to request 
reconsideration for payment. The Plan denied your request. The Plan says the provider is out-of-network and it 
was determined these services were not urgent or emergent. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for Administration of vaccines provided on January 3, 
2022 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the requested item is a medical necessity for 
you. The Plan denied your request. The Plan says medical necessity rules for the requested item have not been 
met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our reviewer says 
that the requested item is not medically reasonable and necessary in this case. Our physician reviewer found 
that you have no diagnosis of COPD, thoracic restrictive disease, or generalized neuromuscular disease. There 
is no arterial blood gas (ABG) study documenting carbon dioxide (CO2) retention. You do not qualify for a 
ventilatory assist device.  
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve three abutment supported crowns (D6063) and three 
implant supported crowns (D6065). 
 
You asked the Plan to pre-approve dental services. You say that these services are necessary. The Plan denied 
your request. The Plan says these services are not covered by your dental benefit. 
 
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 pre-approve three 
abutment supported crowns (D6063) and three implant supported crowns (D6065).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the entire copayment for a comprehensive audiometry 
evaluation and a tympanometry provided on December 10, 2021. 
 
You asked the Plan to waive the copayment for a comprehensive audiometry evaluation and a tympanometry. 
You say that you had the hearing test at the doctor's office, and then they had you go in to see the doctor to get 
the results of the hearing test, which you did. You also say that the doctor suggested that you make an 
appointment to have a tube inserted into your right ear because there may be moisture behind the ear drum, and 
you paid your $45 copayment. You also say that anything that had to do with that visit should have been covered under the $45 copayment, your portion of it anyway. The Plan denied your request. The Plan says you were charged the correct cost sharing amount. 
 
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 $20 
copayment for each hearing exam/test.  
 
You have been asked to pay a $20 copayment for a comprehensive audiometry evaluation and a tympanometry. 
A comprehensive audiometry evaluation and a tympanometry fall within the Hearing 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 entire copayment for a comprehensive audiometry evaluation and a 
tympanometry provided on December 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on September 2, 
2021. 
 
You asked the Plan to waive the copayment for the office visit. You say that the services should be covered as 
you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied correctly 
based on the services provided. 
 
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 $5 
copayment for Physician/Practitioner services, including doctor's office visits.  
 
 
  You have been asked to pay a $3.30 copayment for the office visit, which is less than the standard $5. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for an office visit provided on September 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug test provided on December 20, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for drug test. You say that you would like to request reconsideration for payment. 
The Plan denied your request. The Plan says the provider is out-of-network and authorization is required prior 
to an out-of-network visit. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for drug test provided on December 20, 2021 by an 
out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs in-house services and if she is sent 
home she will be placed back in the hospital. The Plan denied your request. The Plan says IRF is not medically 
necessary and the enrollee can safely receive the services they need in another setting such as in a skilled 
nursing facility, at home with home health services or at home with outpatient therapy. 
 
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 complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient rehab stay. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve block with imaging guidance (64454). 
 
You asked the Plan to pre-approve genicular nerve block. You say that the enrollee needs this injection due to 
chronic knee pain after total replacement of both knee joints. The Plan denied your request. The Plan says this 
procedure is considered unproven and investigational and therefore 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 genicular nerve block. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is a 61-year-old female with bilateral knee pain due to osteoarthritis, 
status post total knee replacements in 4/2021 and 6/2021.  She has continued to have chronic left knee pain that 
is severe with weight-bearing and aggravated by physical activities. The review has determined that the 
requested genicular nerve block is not medically reasonable or necessary. 
 
Genicular nerve blocks and genicular nerve radiofrequency ablation are considered investigational and not medically necessary for the treatment of chronic knee pain, including, but not limited to any of the following:  
degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee replacement; as a treatment 
following knee replacement; or as a treatment for individuals who are not candidates for knee replacement 
surgery.  
 
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 have not been met. Therefore, we decided that the Plan 
does not have to pre-approve genicular nerve block with imaging guidance (64454).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug test (G0480) rendered by the out-of-network (OON) 
provider on December 16, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
 
 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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the drug test (G0480) rendered by the out-of-network (OON) provider on  
December 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a foot, insert, removable, molded to patient model, 
longitudinal/ metatarsal support (L3020). 
 
You asked the Plan to pre-approve foot orthotics. You say that the pain is unbearable and due to chemo, you 
are unable to walk or leave your home. Your feet are always burning. You are on a fixed income and cannot 
afford to pay for orthotics out of pocket. The Plan denied your request. The Plan says this item is not a covered 
benefit. 
 
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 a foot, insert, removable, molded 
to patient model, longitudinal/ metatarsal support (L3020).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on November 19, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the rendering provider is a non-participating provider, and there is no 
referring provider involved in these services. The Plan also says that they did not authorize any services for this 
provider or this facility. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on November 19, 2021, by 
an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical extraction (D7210) and bone replacement 
graft (D7953) to be provided by an oral surgeon. 
 
You asked the Plan to pre-approve dental services performed by an oral surgeon. You say that these services 
are medically necessary and must be performed by an oral surgeon. The Plan denied your request. The Plan 
says services performed by anyone other than a participating general dentist are excluded from coverage under 
your benefit. An oral surgeon is a dental specialist. 
 
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. The Plan requires 
supplemental dental care be performed by a participating general dentist. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, items or services received from an oral 
surgeon are excluded from coverage under this benefit. In addition, the bone replacement graft is not listed as a covered service regardless of who provides the services. Therefore, we decided that the Plan does not have to 
pre-approve a surgical extraction (D7210) and bone replacement graft (D7953) to be provided by an oral surgeon.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computer-assisted surgical navigational procedure used 
during a hip replacement on August 3, 2021, billed with code 20985. 
 
You asked the Plan to pay for the computer-assisted surgical navigational procedure. You say that this should 
be covered due to medical necessity. The Plan denied your request. The Plan says this service is not considered 
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 computer-assisted surgical navigational 
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 limited published, large-scale, long-term peer-
reviewed literature that shows this request to be an effective and/or safe treatment for the noted pathology. Further research is needed. There is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. Therefore, the requested computer-assisted 
surgical navigational procedure for hip surgery, in this case, was 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 the computer-assisted surgical navigational procedure have not been met. 
Therefore, we decided that the Plan does not have to pay for the computer-assisted surgical navigational 
procedure used during a hip replacement on August 3, 2021, billed with code 20985.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical implant placement (D6010), second stage 
implant surgery (D6011), custom abutment (D6057), abutment supported crown (D6059), bone replacement 
graft (D4263) and biological materials to aid in soft and osseous tissue regeneration (D4265) for tooth #30. 
 
You asked the Plan to pre-approve dental services. You say that these services are necessary. The Plan denied 
your request. The Plan says these services are not covered by your dental benefit. 
 
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 
surgical implant placement (D6010), second stage implant surgery (D6011), custom abutment (D6057), 
abutment supported crown (D6059), bone replacement graft (D4263) and biological materials to aid in soft and 
osseous tissue regeneration (D4265) for tooth #30.