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

 
We decided that the Plan does not have to pre-approve a Dopamine Transporter (DaT) Scan 
 
You asked the Plan to pre-approve the DaT scan. You say that the enrollee has abnormal gait multifactorial, 
likely due to lumbar spinal stenosis, underlying polyneuropathy, and arthritis. The appellant says that the 
enrollee's gait has gotten worse, and her lower back pain is radiating down to lower extremities. The appellant 
says that the documentation provided supports the need for a SPECT test. The Plan denied your request. The 
Plan says the records do not show that the enrollee has had any medication trials. 
 
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 DaT scan. Our reviewer says that 
the DaT scan is not considered medically reasonable and necessary in this case. Our physician reviewer found a 
diagnosis of Parkinson's Disease (PD) is generally made based of a combination of clinical history and 
examination. A DaT scan is generally ordered and performed when there is clinical suspicion of PD, but a 
differentiation cannot be made from a syndrome such as essential tremor on exam. DaT scans are otherwise not 
recognized as being diagnostic for Parkinson's Plus syndromes either. In this case the enrollee is really only 
noted to have problems with their gait/ambulation. This is not necessarily a sign of PD, particularly with the enrollee's other medical conditions that can be contributing to her symptoms. 
 
In this context, based on the notes provided for review the requested DaT scan would not be the most 
appropriate service or level of care that could be provided to the member at this time. Nor would it be readily 
furnished in a manner consistent with standards of care/practice. For these reasons this request would not be 
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 the DaT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Dopamine Transporter (DaT) Scan
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Leqvio (inclisiran) treatments. 
 
You asked the Plan to pre-approve the requested use of Leqvio. You say that this is a necessary treatment. The 
Plan denied your request. The Plan says that there has not been a trial of a second statin and also, it is not clear 
that you are unable to self-inject. 
 
Please note: The criterion regarding self-injection was disregarded as the compendia citations do not indicate 
that Leqvio is currently appropriate for self-injection. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 requested use of Leqvio. Our 
reviewer says that the requested use of Leqvio is shown to be medically reasonable and necessary in this case. 
Our physician reviewer found the enrollee is a male with coronary artery disease (CAD) and hyperlipidemia. 
The provider at the Heart & Vascular Institute documents a need for Leqvio. The enrollee has recurrent CAD 
with numerous stents through the years. The enrollee is having anginal symptoms identical to his previous 
angina. The enrollees cholesterol and LDL are elevated. It is documented that the enrollee has been intolerant 
of statin medications, including simvastatin, atorvastatin, and rosuvastatin.  
 
Leqvio is indicated as an adjunct to diet and maximally tolerated statin therapy (which in this case is zero) for 
the treatment of adults with heterozygous familial hypercholesterolemia or clinical atherosclerotic 
cardiovascular disease, who require additional lowering of low-density lipoprotein cholesterol. This request is 
medically reasonable and necessary and is likely to be safe and effective. 
 
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 requested use of Leqvio have been met. Therefore, we decided that the Plan 
has to pre-approve Leqvio (inclisiran) treatments.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (code 99203) you had with a chiropractor on 
May 27, 2022. 
 
You asked the Plan to pay for the chiropractic office visit. You say that you tried physical therapy, but it did 
not resolve your back pain.  You said that you moved your treatment to a chiropractic provider. The Plan 
denied your request. The Plan says office visits with a chiropractor are not covered. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit (code 99203) you had with a chiropractor on May 27, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy visits x8 to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve physical therapy visits. You say that you need physical therapy, and this 
location is more easily accessed. The Plan denied your request. The Plan says the service can be provided by an 
in-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 items/services at issue in this appeal. 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 
physical therapy visits x8 to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an orthopedic surgery consult to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve the orthopedic surgery consult. You say that you saw this provider in the 
past for shoulder surgery and would like to return to him. The Plan denied your request. The Plan says there are 
several providers available in-network who can provide this service. 
 
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 items/services at issue in this appeal. 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 
an orthopedic surgery consult to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve BRCA 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 criteria for coverage are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that BRCA testing is covered for individuals with any 
cancer diagnosis. 
 
We looked at the file and Medicare rules. The records show that you do not have a personal diagnosis of 
cancer. Based on this information, we decided that Medicare rules for coverage of these services have not been 
met. Therefore, we decided that the Plan does not have to pre-approve BRCA genetic testing.  
 
LCD L36161 referenced by the Plan is retired and was not used in the MAXIMUS determination.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve substance abuse treatment visits to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the substance abuse treatment visits. You say that the services were 
medically necessary. The Plan denied your request. The Plan says there are network providers available. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve substance 
abuse treatment visits to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ankle foot orthosis to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve an ankle foot orthosis. You say that it is medically necessary for you to 
receive the equipment. The Plan denied your request. The Plan says the requested provider is an OON provider 
and there are in-network providers available that can provide the requested service the enrollee needs. 
 
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 items/services at issue in this appeal. 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 
an ankle foot orthosis to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an electron beam tomography (EBT) treatment provided on 
March 28, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an electron beam tomography (EBT) treatment. You say that this was necessary 
to figure out how to treat the beneficiary. This should be covered. The Plan denied your request. The Plan says 
this is an experimental test that is not covered by Medicare. Therefore, the payment amount is correct. 
 
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 electron beam tomography (EBT) treatment 
provided on March 28, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visit to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve office visit. You say that you need to be seen as soon as possible by a 
neurologist. The Plan denied your request. The Plan says the enrollee must receive their care from a network 
provider (for more information about this, see Section 2 in this chapter). In most cases, care the enrollee 
receives from an out-of-network provider (a provider who is not part of our plans network) will not be 
covered. 
 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 items/services at issue in this appeal. 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 
office visit to be provided 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 heavy-duty power wheelchair (K0825). 
 
You asked the Plan to pre-approve the heavy-duty power wheelchair. You say that this power chair is 
medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that a Heavy Duty Power Wheelchair is covered for a 
beneficiary weighing 285  450 pounds.  
 
We looked at the file and Medicare rules. The enrollee's weight is 276 pounds. Based on this information, we 
decided that Medicare rules for coverage of the heavy-duty power wheelchair have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a heavy-duty power wheelchair (K0825).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet injections. 
 
You asked the Plan to pre-approve facet injections. 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 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 facet injections. 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 information about your range of motion, facet loading tests and neurologic 
exam documented. Therefore, at this time, the request is deemed 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 facet injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve facet injections.
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 you believe IRF care is medically necessary. You 
say that IRF care will get you walking and up out of bed so you can get back to yourself. The Plan denied your 
request. The Plan says IRF is not medically necessary. Your therapy needs will be longer than what IRF can 
provide. You do not need medical monitoring by a rehabilitation doctor. 
 
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 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 IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ztlido. 
 
You asked the Plan to pre-approve Ztlido. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
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 Ztlido.  
 
Benefits for Ztlido 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve specialist office visits to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the specialist office visits. You say that you would like to see this specific 
provider for your care. The Plan denied your request. The Plan says network providers are available to provide 
necessary care. 
 
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 items/services at issue in this appeal. 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 
specialist office visits to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arthrodesis of the sacroiliac joint. 
 
You asked the Plan to pre-approve arthrodesis of the sacroiliac joint. 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 minimally-invasive surgical (MIS) fusion of the 
sacroiliac (SI) joint is considered medically necessary when specific criteria are 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 arthrodesis of the sacroiliac joint. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found there is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception to guidelines. Therefore, the enrollee does not meet the coverage criteria detailed in the 
LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of arthrodesis of the sacroiliac joint have not been met. Therefore, we decided that 
the Plan does not have to pre-approve arthrodesis of the sacroiliac joint.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for crutches provided on May 16, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for crutches. You say that this cost will cause you a financial hardship, and the 
facility you had the procedure in, choose where to get the crutches. You were unaware. The Plan denied your 
request. The Plan says there was no preauthorization for an Out-Of-Network provider or facility, and this was 
not an emergency. Therefore, the payment is correct. 
 
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 crutches provided on May 16, 2022, by an out-of-
network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing provided on May 23, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the genetic testing. You say that the service is medically necessary. The Plan 
denied your request. The Plan says a referral/authorization was not obtained prior to services being rendered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The 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 genetic testing provided on May 23, 2022, by an 
out-of-network (OON) provider.