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

 
We decided that the Plan does not have to pre-approve DetermaRx + EGFR 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 services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that predictive testing for non-small cell lung cancer 
(NSCLC) is covered 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has metastatic 
adenocarcinoma of the lung. The records do not contain documentation that the enrollee is sufficiently healthy 
to tolerate chemotherapy and that adjuvant platinum-containing chemotherapy is being considered. The documentation does not sufficiently demonstrate that the testing is 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve DetermaRx + EGFR testing.  
 
Local Coverage Determination (LCD) L34519 referenced by the Plan is not valid for the state of California 
where the testing is performed and was not used in the MAXIMUS determination.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve anesthesia for intraoral procedures (CPT code 00170). 
 
You asked the Plan to pre-approve the dental anesthesia. You say that the services are necessary. The Plan 
denied your request. The Plan says the enrollees needs can be met with a local anesthetic with close 
monitoring in an ambulatory setting. 
 
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 dental anesthesia. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation does not support that the coverage criteria for sedation anesthesia 
for the extraction of teeth number's 14 and 18 are met in this case. 
 
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 dental anesthesia have not been met. Therefore, we decided that the Plan 
does not have to pre-approve anesthesia for intraoral procedures (CPT code 00170).
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for an E0118 Crutch substitute or Platform crutch.
You asked the Plan to provide coverage for this item. You say that this item was medically necessary. The Plan
denied your request. The Plan says this item is not covered by Medicare. Maximus overturned the Plans denial
as medically necessary. The Plan requested a reopen and stated that while this item may have been medically
beneficial, its simply not covered by Medicare.
The Plan is correct in this case. The Plan covers all items that Medicare covers. Medicare rules state that an
E0118 crutch substitute or Platform crutch is not an item covered by Medicare.
While this item may be appropriate for your use, neither the Plan nor Medicare offers coverage for this item.
Therefore, we decided that the Plan does not have to provide coverage for an E0118 Crutch substitute or
Platform crutch.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 81298 and 81295 provided on June 18, 2021. 
 
You asked the Plan to pay for codes 81298 and 81295. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that codes 
81298 and 81295 are column II codes to column I code 81432 with a modifier indicator of 0.  The column II codes are therefore not payable. Based on the claim submitted, Medicare billing criteria have not 
been met. Therefore, we decided that the Plan does not have to pay for codes 81298 and 81295 provided on 
June 18, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the VeriStrat assay provided on April 4, 2022. 
 
You asked the Plan to pay for the Veristrat assay. You say that this test is coverable. The Plan denied your 
request. The Plan says this test was not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that genetic testing is coverable when the test is medically 
necessary for the specific patient and will be used to determine the patient's treatment. 
 
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 Veristrat assay. Our reviewer says that 
the Veristrat Assay was not medically necessary. Our physician reviewer found Biodesix VeriStrat test is a 
predictive and prognostic blood-based proteomic test for patients with advanced non-small cell lung cancer. 
The test is used to assess disease aggressiveness by characterizing host response to the tumor, classifying 
patients as either VeriStrat-Good (VS-G) or VeriStrat-Poor (VS-P). The test has been shown to be predictive for EGFR targeted agents in second-line treatment, after progression on or after platinum based chemotherapy. 
VeriStrat test results are available to ordering physicians within 72 hours. For this particular patient, this assay 
was not performed in relation to second line treatment and is therefore 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 the Veristrat assay have not been met. Therefore, we decided that the Plan does 
not have to pay for the VeriStrat assay provided on April 4, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the office visit (99205) provided on October 19, 2020. 
 
You asked the Plan to pay for the evaluation and management service. You say that the office billing specialist 
was hospitalized. You say that claims were misplaced. You say that the provider did not realize this had 
happened. You also say that you would appreciate if an exception could be made. The Plan denied your 
request. The Plan says that the claim was not filed timely. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the file includes a claim for the same date of service and procedure 
code that the plan received on October 20, 2020. The file does not support that the plan has substantiated their 
denial that the claim was not received within 12 months of the date of service. Therefore, we decided that the 
Plan has to pay for the office visit (99205) provided on October 19, 2020.  
 
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: 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 
the enrollee. The Plan denied your request. The Plan says the requested item is not medically necessary. 
 
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 the provided records document that the home ventilator is being requested for use in average volume 
assured pressure support (AVAPS) mode with auto-titration (AE) which could instead be provided by a BiPAP 
device with AVAPS and a back-up rate. 
 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that 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. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found although further rehabilitation services would be appropriate to improve function, as 
a practical matter, the intermittent skilled services can be provided at a lower level of care than a skilled 
nursing facility. Admission to a SNF for inpatient skilled rehabilitation services is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a combination skin protection and positioning seat 
cushion. 
 
You asked the Plan to pre-approve the cushion. You say that this cushion will be beneficial, as you sleep in a 
lift chair, and cannot sleep in a bed. The Plan denied your request. The Plan says this is not going to be used in 
a wheelchair. 
 
The Plan must follow Medicare rules. Medicare rules say that if the beneficiary does not have a covered 
wheelchair, then the cushion will be denied as not reasonable and necessary. 
 
This requested cushion is meant to be used in a lift chair. It is only covered for a wheelchair, which you do not 
have. Based on this information, we decided that Medicare rules for coverage of the cushion have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a combination skin protection and positioning 
seat cushion.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of an implantable loop recorder (ILR). 
 
You asked the Plan to pre-approve insertion of an ILR. 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 cardiac event monitors are covered 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 insertion of an ILR. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found based on current guidelines and the 
documentation provided, there is insufficient clinical evidence to support the medical appropriateness and 
necessity of replacing your old ILR with a new ILR. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of insertion of an ILR have not been met. Therefore, we decided that the Plan does 
not have to pre-approve insertion of an implantable loop recorder (ILR).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter (K0801). 
 
You asked the Plan to pre-approve a power scooter. You say that you are having difficulty moving inside and 
outside your home. The Plan denied your request. The Plan says this was requested for use outside the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a power scooter (K0801).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 1 power operated vehicle (POV). 
 
You asked the Plan to pre-approve these services. You say that you need the scooter to go out to get your mail, 
to the club house, and to exercise. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a Group 1 power operated vehicle (POV).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI), of the abdomen; 
without contrast material(s), followed by with contrast material(s) and further sequences (74183). 
 
You asked the Plan to pre-approve this service. You say that this service is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of the 
requested service. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 this service. Our reviewer says that this 
service is not medically necessary. Our physician reviewer found that in this case the record indicates that the 
enrollee had a gallbladder polyp demonstrated by ultrasound in 2016. The record does not indicate that any 
further imaging was performed. A follow-up ultrasound would be indicated at this time prior to the requested 
study. The requested service is not medically necessary and reasonable for the diagnosis and treatment for the 
enrollee's clinical condition at this time. The elements of the coverage criteria are not satisfied. The requested 
service cannot be 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 this service have not been met.  Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI), of the 
abdomen; without contrast material(s), followed by with contrast material(s) and further sequences (74183).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve aluminum right side guards. 
 
You asked the Plan to pre-approve the guards. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is a convenience item. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve aluminum right side guards.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT), of the left upper extremity; 
without contrast material, followed by contrast material(s) and further sections (73202). 
 
You asked the Plan to pre-approve this service. You say that this service is medically necessary for the 
enrollee. The Plan denied your request. The Plan says this service 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 this service. Our reviewer says that the 
requested service is not medically necessary. Our physician reviewer found that in this case, the record 
indicates that the enrollee has a calcified lymph node in the axilla and an ultrasound guided biopsy has been 
recommended. The provided records do not indicate the medical necessity or reasonableness, as defined by 
Medicare rules, of the requested service at this time. The elements of the coverage criteria are not satisfied.  
The requested service cannot be 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 this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve computed tomography (CT), of the left upper extremity; without contrast material, 
followed by contrast material(s) and further sections (73202).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of cervical spine 
without contrast (72141). 
 
You asked the Plan to pre-approve an MRI of cervical spine without contrast. You say that the service is 
medically necessary. The Plan denied your request. The Plan says the service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 an MRI of cervical spine without 
contrast. Our reviewer says that the requested service is not medically necessary. Our physician reviewer found 
there is no clear documentation of adequate physical therapy, which would be needed for neck pain before 
advanced imaging. 
 
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 MRI of cervical spine without contrast have not been met. Therefore, we 
decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of cervical spine 
without contrast (72141).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services to be provided the requested 
out-of-network provider. 
 
You asked the Plan to pre-approve physician's services to be provided by the requested out-of-network 
provider. The Plan denied your request. The Plan says there are providers in the Plan's network that can provide 
this 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 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 
physician's services to be provided the requested out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the PureWick catheter. 
 
You asked the Plan to pre-approve the PureWick catheter. You say that this is necessary for your condition. 
The Plan denied your request. The Plan says this item is not covered by Medicare or the Plan. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve the PureWick catheter.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine 
without contrast (72148). 
 
You asked the Plan to pre-approve this service. You say that this service is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of the 
requested service. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 this service. Our reviewer says that this 
service is not medically necessary. Our physician reviewer found that in this case the record indicates that the 
enrollee has a hamstring injury. The enrollee has some buttock pain but no red flag symptoms. The record does 
not indicate any neurologic examination abnormality. The enrollee has not tried and failed physical therapy. 
The requested service is not medically necessary and reasonable for the diagnosis and treatment for the 
enrollee's clinical condition at this time. The elements of the coverage criteria are not satisfied. The requested 
service cannot be 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 this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine without contrast (72148).