Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with single power option, 
power tilt, and other accessories (K0856, E2361, E1028x2, E1002, E0955, E1012, E2311, K0108, E2607, 
E2615, K0108). 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that the enrollee has been 
using a power wheelchair for all independent functional mobility. She now requires a new group 3 power 
wheelchair with power tilt. She is unable to complete an effective weight shift by any means throughout the 
day. A group 2 will not meet her needs. Please see the amended PT evaluation attached justifying the need and 
ruling out lesser equipment. The Plan denied your request. The Plan says the enrollee has a diagnosis of CVA 
which qualifies as a neurological condition for which a group 3 power wheelchair base would be medically 
necessary. However, the enrollee does not have a medical need for the single power options included with the 
requested power wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  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 power wheelchair and accessories. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found provided records 
from the enrollee's medical provider do not support that the enrollee is high risk for skin breakdown, has a 
history of pressure ulcer(s) or has had skin flap surgery. Records do not document the enrollee performs 
bladder self-catheterization and is unable to transfer independently or that she has increased muscle tone or 
spasticity. The enrollee's medical record must contain sufficient documentation of her medical condition to 
substantiate the necessity for the type and quantity of items ordered and for the frequency of use or 
replacement. 
 
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 power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a group 3 power wheelchair with single power option, power tilt, 
and other accessories (K0856, E2361, E1028x2, E1002, E0955, E1012, E2311, K0108, E2607, E2615, K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Osteogensis Stimulator. 
 
You asked the Plan to pre-approve an Osteogensis Stimulator. You say that the requested device was deemed 
medically necessary by your surgeon. You say that the requested device will alleviate your pain and speed your 
healing. The Plan denied your request. The Plan says the criteria for coverage have not been met and the 
requested device is not medically necessary or reasonable. 
 
The Plan must follow Medicare rules. The rules say that an electrical bone stimulator is covered for nonunion 
of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial radiographs 
have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment with the 
electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs 
separated by a minimum of 90 days.   
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 an Osteogensis Stimulator. Our 
reviewer says that the criteria for coverage have not been met. Our physician reviewer found detailed 
documentation is not evident regarding this enrollee undergoing a multilevel fusion or having significant risk 
factors for a failed fusion. There are limited large-scale, long-term references showing the safety and efficacy 
of the requested device in this clinical setting. There is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested 
electrical bone growth stimulator, in this case, 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 an Osteogensis Stimulator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an Osteogensis Stimulator.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sixteen (16) additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that the services are 
necessary. The Plan denied your request. The Plan says the requested amount exceeds the limit listed by the 
Plan. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case.  
 
We looked at your request, the records in the case file, and the rules. The 61st trip and beyond is not a covered 
benefit. The Plan contract says up to sixty (60) one-way trips are covered each year (limited to ground transportation only). Therefore, we decided that the Plan does not have to pre-approve sixteen (16) additional 
routine transportation trips.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device. 
 
You asked the Plan to pre-approve the Vertiflex device. You say that the requested surgery will improve the 
enrollee's quality of life. The Plan denied your request. The Plan says the requested surgery is considered 
experimental and investigational as it is not identified as widely used and generally accepted for the proposed 
use as reported in nationally recognized peer-reviewed medical literature published in the English language. 
 
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 Vertiflex device. Our reviewer says 
that the Vertiflex device is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Vertiflex device is considered experimental 
 
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 Vertiflex device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epidural steroid injections. 
 
You asked the Plan to pre-approve epidural steroid injections. You say that the records provided support the 
need for the requested injection services. The Plan denied your request. The Plan says they do not have a pain 
or function scale done by the doctor that shows there is severe pain and/or other symptoms that impact quality 
of life or daily function. The Plan says that they have not received any imaging study that shows narrowing of 
the spine due to a ruptured spine disc, a bone spur, and/or severe wear and tear on the discs in the spine. 
 
The Plan follows Medicare rules. Medicare rules say that epidural steroid injections are covered for certain 
indications.  
  
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 epidural steroid injections. Our 
reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee has 
had a multitude of prior blocks and it is unclear why additional blocks are being requested. There is no recent 
imaging or evidence of advanced imaging having been done within the past 2 years. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of epidural steroid injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve epidural steroid injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of an implanted loop recorder (ILR) for 
cardiac activity. 
 
You asked the Plan to pre-approve the ILR procedure. You say that this should be approved to monitor the 
cause of the enrollee's reported symptoms. The Plan denied your request. The Plan says this is not shown to be 
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 ILR procedure. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found while the enrollee has a history of atrial fibrillation, there is no documentation 
provided to suggest a history of unexplained syncope or any other apparent indication for an ILR. In summary, 
there is insufficient documentation to support the medical necessity for insertion of an ILR 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 ILR procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve placement of an implanted loop recorder (ILR) for cardiac activity.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on June 23, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you were not aware of the requirement of 
obtaining a prior authorization at the time of rendering services and that you conducted in good faith the 
laboratory testing ordered by the referring provider, who deemed the services to be medically necessary. The 
Plan denied your request. The Plan says the enrollee must receive 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 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 laboratory services provided on June 23, 2022, by 
an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ExoDx testing.
You asked the Plan to pre-approve ExoDx testing. You say that this testing is medically necessary. The Plan
denied your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the Plans
denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for ExoDx testing.
The Maximus Physician Reviewer determined the required criteria were met. The Plan requested a reopen and
argues that the reported PSA of 11 ng/mL falls outside the coverage guidelines specified in the LCD of =4 and
less than 10 ng/mL in men older than 75 years. The medical records show you are a 76-year-old man with an
elevated PSA (11 and rising over the previous few years). You had a negative previous prostate biopsy and
underwent a previous TURP. You wanted to avoid unnecessary invasive evaluations and treatments. The
request was to obtain ExoDX testing, and biopsy only if the result was concerning. The Plan is correct in this
case.
The intended use population for the ExoDx Prostate Test is age 50 or older, PSA 2 - 10 mg/mL, and
considering an initial biopsy. In this case the PSA is over the intended use guidelines, and the proposed biopsy
is not an initial biopsy.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of ExoDx testing have not been met. Therefore, we decided that the Plan does not
have to pre-approve ExoDx testing.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 5, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You are appealing with supporting records. The Plan denied your 
request. The Plan says the enrollee must receive 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 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 April 5, 2022, by an 
out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda (J9271). 
 
You asked the Plan to pre-approve Keytruda. You say that this drug is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the requested drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 Keytruda. Our reviewer says that the 
requested use of Keytruda is not medically necessary. Our physician reviewer found the requested use of 
Keytruda as a first-line therapy is not approved by Food and Drug Administration (FDA) for the enrollee's 
condition. The reviewer found that the major drug compendia only support the use of Keytruda as subsequent 
therapy. Therefore, the reviewer found that the requested use of Keytruda 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 Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda (J9271).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the incision for implantation of cranial nerve (eg: vagus 
nerve) neurostimulator electrode array and pulse generator (64568). 
 
You asked the Plan to pre-approve Vivistim Paired Vagus nerve stimulation. You say that you have ordered 
implantation of the Vivistim Paired Vagus Nerve Stimulation (VNS) system to treat the enrollee's severe upper 
limb deficit and allow the enrollee to regain function of their left upper extremity that was lost after ischemic 
stroke in 2014. The Plan denied your request. The Plan says this request does not meet medical necessity.  
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 Vivistim Paired Vagus Nerve 
Stimulation. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found in this case, the record indicates that the requested device 
is to treat upper extremity motor and sensory deficit secondary to ischemic coverage. This indication is not an 
enumerated condition for which coverage is available and is excluded by rule. The elements of the coverage 
criteria are not satisfied. The requested service is not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vivistim Paired Vagus Nerve Stimulation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the incision for implantation of cranial nerve (eg: vagus 
nerve) neurostimulator electrode array and pulse generator (64568).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Vital Vitamins Multi Collagen Complex Capsules provided 
on August 23, 2022. 
 
You asked the Plan to pay for Vital Vitamins Multi Collagen Complex Capsules. You say that your doctor 
recommended that you take collagen capsules. The Plan denied your request. The Plan says collagen is not 
eligible for reimbursement under the Pick Your Perks Benefits. 
 
The Plan contract covers a supplemental Pick Your Perks reimbursement OTC benefit. The Plan says ineligible 
items include, but are not limited to, the following: alternative medicines such as botanicals herbals, probiotics 
and nutraceuticals. 
 
We looked at the file and the Plans rules. The file shows that collagen is not eligible for reimbursement under 
the Pick Your Perks OTC benefit. Therefore, we decided that the Plan does not have to pay for Vital Vitamins 
Multi Collagen Complex Capsules provided on August 23, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you are blind and have 
severe Blepharospasm. You say that the only doctor you can see is an hour away. You say that you had to 
cancel your treatment for burning nerves for pain, due to hot having any rides to your appointments. The Plan 
denied your request. The Plan says you are not eligible for additional routine transportation trips until January 
1, 2023. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 20 one-way routine transportation trips per year.   
We looked at your request, the records in the case file, and the rules. The records show that you have received 
coverage for 20 one-way routine transportation trips in the 2022 calendar year. Based on this information, we 
decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, 
we decided that the Plan does not have to pre-approve additional routine transportation trips.
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 it is medically necessary for the enrollee to receive 
IRF care. The Plan denied your request. The Plan says the criteria for IRF admission were not met and the 
enrollee can receive the services they need in a less intensive setting like a skilled nursing facility. 
 
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 rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program. The enrollee continues to have a need for skilled 
therapy with ongoing safety concerns and a potential for functional improvement however, the documentation 
doesnt support that they would meet criteria for admission to an acute inpatient rehabilitation facility.   
 
There is no indication that the enrollee would require skilled rehabilitation in an IRF, participating in 
rehabilitation services 15 hours a week, under the supervision of a physician with at least 3 visits weekly to 
regain or maintain their functional status. The enrollee can receive further services at a lower 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 IRF admission and services.
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 you are eager to participate in the three hours of 
aggressive rehabilitation that an IRF will offer you. You say that your doctor says you will need closer medical 
management of your current medical needs and disease. The Plan denied your request. The Plan says you do 
not meet the criteria for IRF admission. 
 
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 your 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.