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

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent, genicular nerve 
branches including imaging guidance, when performed (64624). 
 
You asked the Plan to pre-approve destruction by neurolytic agent, genicular nerve branches including imaging 
guidance. You say that this is medically necessary. The Plan denied your request. The Plan says genicular 
radiofrequency ablation is considered experimental, investigational, and/ or unproven and is excluded from 
coverage. 
 
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 destruction by neurolytic agent, 
genicular nerve branches including imaging guidance. Our reviewer says that the requested items/services are 
not considered medically reasonable and necessary in this case. Our physician reviewer found the provided 
medical records and review of the current peer-reviewed medical literature do not clearly document that use of 
genicular nerve ablation has been shown in controlled studies in a Centers for Medicare and Medicaid Services 
approved journal to result in sustained long term health benefits in patients with osteoarthritis with intractable 
neuropathic pain of the right knee or that it is standard 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 destruction by neurolytic agent, genicular nerve branches including imaging 
guidance have not been met. Therefore, we decided that the Plan does not have to pre-approve destruction by 
neurolytic agent, genicular nerve branches including imaging guidance, when performed (64624).
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for SelectMDx testing provided to the enrollee on January 18, 2023.

You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial. The
Plan requested a reopen and noted that Review of the technical assessment as found on the MolDX program
website (https://app.dexzcodes.com/app#!catalogDetailPage) indicates that the technical assessment for
SelectMDx was not effective until February 17, 2023.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. In this case, the services billed were not available for coverage on the date of service
in question. Medicare rules for payment of this service have not been met. Therefore, we decided that the Plan
does not have to pay for SelectMDx testing provided to the enrollee on January 18, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Padcev. 
 
You asked the Plan to pre-approve Padcev. You say that the requested drug is necessary to treat the enrollee's 
diagnosis. The Plan denied your request. The Plan says the drug requested does not meet the criteria required 
for approval. 
 
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 Padcev. Our reviewer says that the 
requested drug does not meet the criteria necessary for approval. Our physician reviewer found the requested 
drug is not FDA-approved for the enrollee's diagnosis and is not supported by any major drug compendia or 
clinical research that appears in a CMS-approved medical journal. However, the enrollee should be a candidate 
for cisplatin-based therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Padcev have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Padcev.
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for SelectMDx testing provided to the enrollee on January 26, 2023.

You asked the Plan to pay for this testing. You say that this claim should be paid. The Plan denied your
request. The Plan says this testing as billed was not available at the time of service. Maximus overturned the
Plans denial. The Plan requested a reopen and noted that Review of the technical assessment as found on the
MolDX program website (https://app.dexzcodes.com/app#!catalogDetailPage) indicates that the technical
assessment for SelectMDx was not effective until February 17, 2023.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. In this case, this claim could not be paid as billed as this service was not available for
payment on the date of service. 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 pay for SelectMDx testing
provided to the enrollee on January 26, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage for routine transportation (A0170). 
 
You asked the Plan to pre-approve additional mileage for routine transportation. You say that you need 
transportation for your medical appointment. The Plan denied your request. The Plan says your benefit only 
allows 48 one-way trips with each one-way trip not exceeding 50 miles of driving distance. 
 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 routine transportation when the driving distance for a one-way trip is within 50 miles.  
 
We looked at your request, the records in the case file, and the rules. Specifically, the provider is located 59 
miles away from your residence. The Plan only covers distances up to 50 miles. Based on this information, we 
decided that the Plans rules for coverage of routine transportation have not been met. Therefore, we decided 
that the Plan does not have to pre-approve additional mileage for routine transportation (A0170).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on August 10, 2022.

You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says there are insufficient records provided to support the services billed. Maximus
overturned the Plans denial for insufficient information in the case file. The Plan requested a reopen and
demonstrated that they attempted to have additional records submitted from you several times with no response
to their request.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that the provider,
supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to
determine whether payment is due and the amount of payment.

We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient
information in the record to determine if Medicare rules for coverage of these services have been met.
Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on August 10,
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that appealing with supporting records. The Plan denied 
your request. The Plan says based on Medicare guidelines, the Inpatient Rehabilitation Facility (IRF) services 
requested do not meet the requirements for approval. 
 
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 the complexity of the patient's nursing, medical and rehabilitation can be provided in 
a lower level of care and does not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. Our physician reviewer also found that the enrollee requires treatment by multiple therapies, 
including physical therapy and occupational therapy, but this can be provided in 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64628, 64629). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is investigational, and not covered. 
 
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 Intracept 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 no magnetic resonance imaging showing only modic changes without facet 
degenerative joint disease or stenosis. The cause of pain is not clear. 
 
   
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure (64628, 64629).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you disagree with this denial. 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 foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a left sacroiliac joint nerve RFA. 
 
You asked the Plan to pre-approve the RFA. You say that the requested procedure is medically necessary for 
the enrollee. The Plan denied your request. The Plan says this procedure is 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 an RFA. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is considered experimental therapy because of the wide variation in efficacy reported in the 
peer reviewed literature. Therefore, the request is deemed not 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 an RFA have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a left sacroiliac joint nerve RFA.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve minuteman G5 interspinous device. 
 
You asked the Plan to pre-approve minuteman G5 interspinous device. You say that you are requesting 
reconsideration for the denied claim. The Plan denied your request. The Plan says more research is needed to 
show safety and efficacy of the procedure and the devices. 
 
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 minuteman G5 interspinous device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found no compelling rationale is presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of minuteman G5 interspinous device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve minuteman G5 interspinous device.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64628, 64629). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this is medically necessary. The Plan 
denied your request. The Plan says the medical records showed that the enrollee has low back pain, thought to 
be vertebrogenic in nature. There was no documentation of diagnostic injections or nerve studies performed 
confirming the basivertebral nerves are the source of the enrollee's pain. 
 
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 Intracept 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 no magnetic resonance imaging showing only modic changes without facet 
degenerative joint disease or stenosis. The cause of pain is not clear.  
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure (64628, 64629).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Trazodone. 
 
You asked the Plan to pre-approve Trazodone. You say that the medication is medically necessary. The Plan 
denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
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 Trazodone.  Benefits for Trazodone 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 Stereotactic Body Radiation Therapy (SBRT). 
 
You asked the Plan to pre-approve SBRT. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested services are 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 SBRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found you have prostate cancer. Standard therapies for prostate cancer include prostatectomy, 
interstitial brachytherapy and Intensity-modulated radiation therapy (IMRT) delivered over 7+ weeks (or 
shorter courses with approximately 2.5 Gy fractions- as being investigated in a national cooperative group 
trial). The current literature and National Comprehensive Cancer Network (NCCN) guidelines support consideration of SBRT as an option for monotherapy in patients with low, intermediate or high-risk disease risk 
disease. They do not support its use in conjunction with additional radiation (external beam or brachytherapy). 
However, SBRT is not intended to be used as a boost. Furthermore, there are no consensus guidelines or 
published cooperative studies that support combined SBRT and brachytherapy. While the addition of SBRT to 
brachytherapy is arguably less costly than a course of IMRT and brachytherapy, and this treatment approach 
may have promise, it remains investigational and (based on NCCN guidelines or ASTRO model policy) would 
not meet the criteria of being furnished in accordance with accepted standards of medical practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SBRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Stereotactic Body Radiation Therapy (SBRT).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous laminotomy/laminectomy (intralaminar 
approach) for decompression of neural elements (0275T). 
 
You asked the Plan to pre-approve percutaneous laminotomy/laminectomy. 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 PILD 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 percutaneous 
laminotomy/laminectomy. Our reviewer says that the services are not medically necessary. Our physician 
reviewer found detailed documentation is not evident regarding her being enrolled in a Medicare-approved 
clinical study. The Medicare NCD does not approve this procedure outside of a supported clinical study. There 
is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Therefore, the enrollee does not meet the coverage criteria detailed in the NCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of percutaneous laminotomy/laminectomy have not been met. Therefore, we 
decided that the Plan does not have to pre-approve percutaneous laminotomy/laminectomy (intralaminar 
approach) for decompression of neural elements (0275T).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health/care assistance. 
 
You asked the Plan to pre-approve home health/care assistance. You say that the services are necessary. The 
Plan denied your request. The Plan says this is not a Medicare-certified provider. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pre-approve home health/care assistance.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC) with multiple 
power options. 
 
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 a Group 3 PWC with multiple power options 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 criteria for coverage are not met. Our physician reviewer found the records do not support that the enrollee 
is at high risk for skin breakdown and is unable to perform a functional weight shift, has a history of pressure 
ulcers, or has had skin flap surgery. She does not perform bladder self-catheterization. She does not have 
increased muscle tone or spasticity to meet the criteria for the power tilt and/or recline and thus the multiple 
power option base. The records do not support that the Group 3 PWC with multiple power options is 
reasonable and medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Group 3 power wheelchair (PWC) with multiple power options.