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

 
We decided that the Plan does not have to pre-approve a transcatheter aortic valve replacement (TAVR) 
procedure.  
 
You asked the Plan to pre-approve the requested TAVR procedure. You say that this is felt to be the only 
viable option for treating this enrollee's condition. The Plan denied your request. The Plan says there is no 
evidence of the required clinical trial participation.  
 
The Plan must follow Medicare rules. Medicare rules say that when TAVR is performed for an indication that 
is not expressly FDA-approved, the clinical trial required for coverage must meet certain additional criteria.   
 
We looked at the file and Medicare rules. It is noted in your appeal request that this service is being requested 
for a non-FDA-approved indication. While there is a clinical registry for TAVR patients, this does not appear 
to include review of the 1-year pre- and post-procedure quality of life assessment that is required for non-FDA 
-approved uses. The file did not verify the type of system that is to be used, and it could not be confirmed that 
there is a clinical trial that the enrollee is planned to participate in. This was despite attempts from the Plan to 
obtain said information from the treating provider, per Maximus request.  
Based on this information, we decided that Medicare rules for coverage of the requested TAVR procedure have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a transcatheter aortic valve 
replacement (TAVR) procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99220 billed for date of service April 23, 
2022.  
 You asked the Plan to pay for procedure code 99220. You say that this claim was billed correctly and these 
services were medically necessary. The Plan denied your request. The Plan says the number of units billed 
exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 99220 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 99220 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99220 billed for date of service April 23, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve an implantable neurostimulator electrode (L8680), and 
percutaneous implantation of neurostimulator electrode array (63650). 
 
You asked the Plan to pre-approve the implantation of a neurostimulator electrode. You say that this is 
medically necessary for the enrollee. The Plan denied your request. The Plan says that there was no 
documentation to show the failure of surgical therapies for your lower back. 
 
The Plan follows Medicare rules. Medicare rules say that implantation of dorsal column or depth brain 
stimulators or services and supplies related to such implantation may be approved when all of the conditions 
have been 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 the implantation of a neurostimulator 
electrode. Our reviewer says that the request for the implantation of a neurostimulator electrode is medically 
necessary. Our physician reviewer found the provided documentation indicates the enrollee has failed 
conservative therapy and medication trials. The documentation indicates the enrollee has psychological 
clearance. The reviewer also found that the progress note refers to a surgical consultation and the screening 
form refers to not being a further surgical candidate. Therefore, the reviewer found that the request for the 
implantation of a percutaneous neurostimulator electrode is medically reasonable and necessary 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 implantation of a neurostimulator electrode have been met. Therefore, we 
decided that the Plan has to pre-approve an implantable neurostimulator electrode (L8680), and percutaneous 
implantation of neurostimulator electrode array (63650).  
 
 
 
 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 pre-approve treatment with Ondansetron tablet. 
 You asked the Plan to pre-approve Ondansetron. You say that the requested drug is a medical necessity for the 
enrollee. 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 drug requested here is not, as prescribed, among the types which are 
covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with 
Ondansetron tablet.  
 
Benefits for Ondansetron 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 radiofrequency ablation of the sacroiliac joint. (64625). 
 
You asked the Plan to pre-approve radiofrequency ablation. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is not medically necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of radiofrequency ablation have not been met. Specifically, radiofrequency ablation of the sacroiliac 
joint is not considered medically necessary. Therefore, we decided that the Plan does not have to pre-approve 
radiofrequency ablation of the sacroiliac joint. (64625).
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 you need hospital care for your complex needs. The 
Plan denied your request. The Plan says the denial of IRF care is correct. 
 
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 your nursing, medical, and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While you may need 
physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that 
you will be able to fully participate in - and benefit from - the intensive rehabilitation therapy program 
provided in an IRF. 
 
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 kyphoplasty. 
 
You asked the Plan to pre-approve kyphoplasty. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee has not tried and failed conservative therapy. 
 
The Plan follows Medicare rules. Medicare rules say that kyphoplasty is covered only when medically 
necessary according to the criteria listed 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 kyphoplasty. Our reviewer says that the 
requirements for coverage of the requested services have not been met. Our physician reviewer found detailed 
documentation is not evident regarding worsening pain. There is no indication of a progression of the body height loss, greater than 25% vertebral body height loss, kyphotic deformity, or a severe impact on daily 
activities. Moreover, there is imaging corroboration of other plausible causes of pain in the middle and low 
back. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve kyphoplasty.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ultralightweight wheelchair (K0005) and additional 
items and accessories (codes E0951 x2, K0040 x2, E0973 x2, E0978, E2607, E2615, E2211 x2, E2213 x2, and 
E0971 x2). 
 
You asked the Plan to pre-approve an ultralightweight wheelchair and additional items and accessories. You 
say that the enrollee's chair is approaching five years old and would like a new one. You also say that you 
would like this request to be reviewed and the denial to be overturned. The Plan denied your request. The Plan 
says the request for a new ultra-lightweight manual wheelchair is understandable, however, given the repairs 
that are necessary, the intact frame and cushion, it is not clear if it is more cost effective to repair the current 
wheelchair or replace it with the requested ultra-lightweight manual wheelchair. The Plan also says the vendor 
should provide the health plan with cost of repair versus replacement quote to determine the most cost-effective 
option. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an ultralightweight wheelchair and 
additional items and accessories. Our reviewer says that this request is not medically necessary. Our physician 
reviewer found the documentation does not indicate that the wheelchair is 5 years old. Our reviewer also found 
that there is no clear indication that the cost of repairs for the current wheelchair would be more than 
replacement value of the wheelchair. 
 
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 ultralightweight wheelchair and additional items and accessories have not 
been met. Therefore, we decided that the Plan does not have to pre-approve an ultralightweight wheelchair 
(K0005) and additional items and accessories (codes E0951 x2, K0040 x2, E0973 x2, E0978, E2607, E2615, 
E2211 x2, E2213 x2, and E0971 x2).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a quantitative calcium scoring (75571). 
 
You asked the Plan to pre-approve a quantitative calcium scoring. You say that this test is necessary. The Plan 
denied your request. The Plan says you do not meet the criteria for coverage. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. Medicare rules also say that quantitative calcium 
scoring is not a covered service and will be denied as not medically necessary. 
 
The test at issue in this appeal, a quantitative calcium scoring, is being requested solely for screening purposes. 
Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not 
have to pre-approve a quantitative calcium scoring (75571).  
 
Your complaint about your unhappiness with the Plans denials of items and services you need is not a valid 
appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. 
Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Injectafer (J1439). 
 You asked the Plan to pre-approve Injectafer. You say that Injectafer is a medical necessity for the enrollee. 
The Plan denied your request. The Plan says step-therapy rules for coverage of Injectafer have not been met. 
 
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 Injectafer. Our reviewer says that 
Injectafer is not medically reasonable and necessary in this case. Our physician reviewer found that the Plan 
requires a trial of drugs Infed (iron dextran) and Venofer (iron sucrose) before they will approve the requested 
drug, Injectafer. Based on the medical records provided, there is no indication that the enrollee has tried and 
failed the required drugs. Based on the medical records provided and the Medicare-approved major drug 
compendia, there is no indication that the Plan's required drugs 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 Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Injectafer (J1439).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve minimally invasive lumbar decompression (0275T). 
 
You asked the Plan to pre-approve minimally invasive lumbar decompression. 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 minimally invasive lumbar 
decompression. 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 compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the 
requested minimally invasive lumbar decompression (MILD) at L3-4 is not medically reasonable or necessary.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of minimally invasive lumbar decompression have not been met. Therefore, we 
decided that the Plan does not have to pre-approve minimally invasive lumbar decompression (0275T).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder test (0012M) provided on March 23, 2023. 
 
You asked the Plan to pay for the Cxbladder test. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for CxBladder are non-
covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder test have not been met. Therefore, we decided that 
the Plan does not have to pay for the Cxbladder test (0012M) provided on March 23, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator surgery to be provided by an 
out-of-network (OON) provider.  
 
You asked the Plan to pre-approve a spinal cord stimulator surgery. You say that the requested provider is one 
of the only doctors that can perform this surgery. The Plan denied your request. The Plan says there are in-
network providers available for the requested surgery. 
 
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 provider at issue in this case is not a network provider with the Plan. 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 spinal cord stimulator surgery. Our reviewer says that the requirements for 
coverage of out-of-network services have not been met. Our physician reviewer found there is no submitted 
documentation regarding any significant abnormalities that would require this procedure to be performed out-
of-network. There is large-scale, long-term peer-reviewed literature that supports this procedure is a safe 
procedure and is not associated with any significant risk factors that would require a specialized provider. The 
Plan has provided documentation showing they have an in-network provider that can perform the requested 
procedure. 
 
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 spinal cord stimulator surgery have not been met.  
 
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 a spinal cord stimulator surgery. Therefore, we decided 
that the Plan does not have to pre-approve a spinal cord stimulator surgery 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 the Minuteman device (22853, 22840 and 22612). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the 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 the services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found current evidence-based medical guidelines and peer-reviewed literature do not fully support the 
interspinous fusion device procedure over the gold standard of lumbar fusion. There is a lack of large-
volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollees medical 
condition as discussed above.  According to the FDA, The HA Minuteman G3-R MIS Fusion Plate is a posterior, non-pedicle supplemental 
fixation device, intended for use at a single level in the non-cervical spine (T1-S1). 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Minuteman device (22853, 22840 and 22612).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zarxio (Q5101). 
 
You asked the Plan to pre-approve Zarxio. You say that the enrollee is in the middle of chemotherapy and 
needs treatment. The Plan denied your request. The Plan says according to the medical records provided, the 
member is enrolled in a clinical trial. The Plan also says that coverage of the requested drug would be deemed a 
routine cost covered by the Medicare Administrative Contractor (MAC). 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve Zarxio as part of a clinical trial. The Plan does not cover routine 
costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-
approve Zarxio (Q5101).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the 
Plan's 10-trip limit. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you need transportation to 
doctor appointments. The Plan denied your request. The Plan says you have exhausted your transportation 
benefit. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 10 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the Plan's 
10-trip limit.