Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity.  
 You asked the Plan to pre-approve Evenity. You say that the enrollee has difficulty swallowing and cannot take 
oral medications. The Plan denied your request. The Plan says the requested drug is subject to step therapy. The 
enrollee must first try or be unable to use the Plan's preferred medications which are: an injectable 
bisphosphonate (e.g., Pamidronate, Zoledronic Acid). 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Evenity. Our reviewer says that the 
requested drug is not medically necessary. Our physician reviewer found the enrollee has not tried and failed 
the required drug(s). There is no documentation provided indicating that the Plan's required drug(s) would 
likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Evenity.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care services provided on 
October 30, 2023. 
 You asked the Plan to pay for the subsequent nursing facility care services. You say that the enrollee was no 
longer in hospice on the date of service. The Plan denied your request. The Plan says Original Medicare is 
responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on October 21, 2023. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the subsequent 
nursing facility care services provided on October 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Proton Beam Radiation Therapy (PBRT) for the
enrollee.

You asked the Plan to pre-approve PBRT. You say that these services are medically necessary. The Plan denied
your request. The Plan says that the requested PBRT is not medically necessary.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for PBRT. Our
Medical Director states that the enrollee has a diagnosis of early stage (T2N0) left breast cancer. Lumpectomy
was performed on February 17, 2023. The enrollee was refusing adjuvant chemotherapy which was
recommended to decrease the chance if local and distant failure. The enrollee also refused standard whole
breast radiation therapy with photons due to concern for toxicity to the heart and lungs. It was determined that
the enrollee would benefit from radiation therapy to the left whole breast, with treatment of the lower axillary
nodes since the enrollee was not willing to consider chemotherapy. The first level appeal states that, given the
enrollee's concern for cardiac toxicity, a reduction in heart dose would be advantageous. "Her tumor bed is
located directly above her heart..." The case file does not contain an imaging report. The available clinical
documentation is insufficient to support that the requested proton beam therapy is/was medically reasonable
and necessary for the enrollee in this case. Our Medical Director found that the enrollee's condition does not
meet criteria for coverage of PBRT.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of PBRT have not been met. Therefore, we decided that the Plan does not have to
pre-approve Proton Beam Radiation Therapy (PBRT) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the compression stockings identified with code A6530 that 
were issued on August 24, 2023. 
 
You asked the Plan to pay for the compression stockings. You say that the items should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the items denied correctly as they do not 
meet the clinical requirements to be approved. 
 The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression 
stockings identified with code A6530 that were issued on August 24, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance treatment without transport on September 8, 
2023. 
 
You asked the Plan to pay for ambulance treatment. You say that the ambulance was called because you fell at 
a doctor's office. They took care of you and stopped the bleeding; you did not want to be transported by the 
ambulance to the hospital. The Plan denied your request. The Plan says ambulance treatment without transport 
is not a payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on September 8, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance treatment without transport on 
September 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve the injection. You say that the enrollee received a lumbar epidural steroid 
injection on October 27, 2023, which resulted in almost 100 % pain relief but for only a short period of time. 
You say that the injection is medically necessary for the enrollee. The Plan denied your request. The Plan says 
an epidural steroid injection 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 the injection. Our reviewer says that an 
epidural steroid injection is not medically necessary.  Our physician reviewer found that the enrollee has an L5-
L1 epidural steroid injection on October 27, 2023, which provided only 4 days of pain relief. However, the 
LCD criteria requires at least 50% pain relief for three months, which was not achieved. Therefore, the request 
is 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 the injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an epidural steroid injection.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance treatment without transport on September 5, 
2023. 
 
You asked the Plan to pay for ambulance treatment. You say that you called the ambulance to help get you 
back in your chair. You did not need or want to go to the hospital. The Plan denied your request. The Plan says 
treatment without transportation is not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on September 5, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance treatment without transport on 
September 5, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled nursing (G0299 x30). 
 You asked the Plan to pre-approve home health services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found twice daily 
home health skilled nursing services are being requested. Daily services are not intermittent and do not meet 
the criteria for home health services. The requested services are not reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health skilled nursing (G0299 x30).
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 the enrollee needs this care to regain previous level 
of function before returning home. The Plan denied your request. The Plan says the enrollees medical condition 
does not require IRF services, and care can be provided in another setting.  
 
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 enrollee's medical, rehabilitation, and nursing needs does not 
require IRF care with an interdisciplinary approach to rehabilitative care. The enrollee's rehabilitation needs 
can be safely provided in an alternate setting.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a dental crown (D2750) provided on September 22, 
2023. 
 
You asked the Plan to pay more for the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says you are responsible for any charged 
amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to pay more for a dental crown (D2750) provided on 
September 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for Prolia provided to the enrollee on March 24, 2023.

You asked the Plan to pay for Prolia. You say that this drug should be covered by the Plan. The Plan denied
your request. The Plan says this claim was billed to the Plan in error. Maximus overturned the Plans denial for
a lack of proof that this drug was obtained from a pharmacy. The Plan requested a reopen and provided the
required documentation.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that, in order to be
eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and
be included in the physician's bill. In this case, we have confirmed that the requested medication was dispensed
by a pharmacy and delivered by the pharmacy to the office for administration. Since the medication did not
represent an expense to the provider and will not be included in the bill, it is not eligible for Part B coverage.
Therefore, we decided that the Plan does not have to pay for Prolia provided to the enrollee on March 24, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the genicular artery embolization. 
 
You asked the Plan to pre-approve the genicular artery embolization. You say that the procedure is medically 
necessary for the treatment of the enrollee's condition and will provide a long-lasting pain relief that will 
improve the enrollee's quality of life. The Plan denied your request. The Plan says the genicular artery 
embolization 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 the genicular artery embolization. Our 
reviewer says that the genicular artery embolization is not medically necessary. Our physician reviewer found 
that the genicular artery embolization is considered experimental and investigational 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 the genicular artery embolization have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the genicular artery embolization.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve InnovaMatrix AC skin substitute (A2001). 
 
You asked the Plan to pre-approve InnovaMatrix AC skin substitute. You say that this is medically necessary. 
The Plan denied your request. The Plan says that InnovaMatrix AC is not considered medically reasonable and 
necessary, as it is not covered for any indication. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 InnovaMatrix AC skin substitute. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found the medical documentation supports that this patient has been suffering with left 
lower extremity wounds for greater than six months. The wounds were not responding to conservative care 
including standard wound debridement, activity modification, offloading, and wound dressings. Two 
applications of InnovaMatrix reduced the ulceration from 350 cm2 to 200 cm2. The patient is also noted to have 
a recent hemoglobin A1c of 7.2, no lower extremity arterial vascular disease, and is in good nutritional health. 
In this particular case the documentation demonstrates that this patient has been suffering with a nonhealing 
left lower extremity ulceration for greater than 6 months. They have failed conservative standard wound care 
treatments. The application of InnovaMatrix advanced skin substitutes would be 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 InnovaMatrix AC skin substitute have been met. Therefore, we decided that the 
Plan has to pre-approve InnovaMatrix AC skin substitute (A2001).  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided from July 26, 2023, to July 
27, 2023. 
 
You asked the Plan to pay for the medication. You say that the medication was provided while at a medical 
facility. 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 pay for self-administered drugs provided 
from July 26, 2023, to July 27, 2023.  
 
Benefits for the medication 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vectibix and capecitabine.  
 
You asked the Plan to pre-approve Vectibix and capecitabine. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says the requested drugs are 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 Vectibix and capecitabine. Our 
reviewer says that the requested drugs are not medically necessary. Our physician reviewer found that the 
requested use of Vectibix and capecitabine is not FDA-approved for the enrollees diagnosis without RAS testing. The use is not supported by one of the major drug compendia or by clinical research that appears in a 
Medicare-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vectibix and capecitabine have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Vectibix and capecitabine.
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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary.  
 
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 enrollee is medically stable and does not need physicians supervision 3 times a 
week in an IRF. At the current functional level, the enrollee needs physical therapy, and occupational therapy. 
The enrollee does not need intensive therapies consisting of at least 3 hours of therapy per day at least 5 days 
per week with multidisciplinary approach in an IRF. Documentation does not support necessity for admission 
to an IRF. The complexity of the enrollees medical, rehabilitation, and nursing needs (combined complexity) 
does not require acute hospital inpatient rehabilitation stay with an interdisciplinary approach to rehabilitative 
care. The enrollees rehabilitation needs can be safely provided in a low intensity alternate setting.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee's admission to an LTACH is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet the Medicare 
criteria for admission to an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be improving with current treatment and should only require 
short-term additional acute care services that can safely be provided at the current facility until more stable and 
appropriate for transfer to a lower level of care. The enrollee does not require services at the LTACH that are not already available at the current facility. Transfer to the LTACH is not medically necessary as it would not 
be clinically advantageous at this time. Completion of treatment at the current facility is 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.