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

 
We decided that the Plan does not have to pre-approve Leqvio 284mg/1.5ml syringe. 
 You asked the Plan to pre-approve the medication. You say that the enrollee has not tried the preferred drug 
due to memory issues. The Plan denied your request. The Plan says the criteria has not been me as the enrollee 
has not tried and failed the preferred drug. 
 
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 the medication. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found in this case the record indicates that the enrollee has age related osteoporosis without 
osteoporotic fracture. The requested medication is a new start. The provided records do not indicate that the 
enrollee has tried and failed the Plan's preferred step one alternative. The record does not indicate that the 
enrollee has a contraindication to or would have an adverse effect from the Plan's preferred step one alternative. 
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 the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Leqvio 284mg/1.5ml syringe.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve heavy duty extra wide hospital bed (E0303). 
 
You asked the Plan to pre-approve heavy duty extra wide hospital bed (E0303). You say that you would like 
the Plan to reconsider their denial. The Plan denied your request. The Plan says you do not meet criteria for a 
heavy duty extra wide hospital bed (E0303). 
 The Plan must follow Medicare rules. The rules say that a heavy duty extra wide hospital bed (E0303) is 
covered if the beneficiary meets one of the criteria for a fixed height hospital bed and the beneficiary's weight 
is more than 350 pounds but does not exceed 600 pounds. In this case, the file shows that the enrollee's weight 
is less than 350 pounds. Therefore, we decided that the Plan does not have to pre-approve heavy duty extra 
wide hospital bed (E0303).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled nursing services.  
 You asked the Plan to pre-approve home health services. You say that the requested home health services are 
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 that the 
provided records do not document any acute or unstable medical conditions or changes in medication or 
treatment which would necessitate any further skilled nursing visits beyond what have already been approved.  
 
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 services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing provided on April 4, 2023. 
 
You asked the Plan to pay for the drug testing. The Plan denied your request. The Plan says this 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 pay for the drug testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the record sent by the provider shows presumptive screening test results which are partially inconsistent with prescription medications, or history and expected results. Definitive confirmation testing was 
medically necessary for only 2 drug classes. The requested drug testing was 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 drug testing have not been met. Therefore, we decided that the Plan does not 
have to pay for the drug testing provided on April 4, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 heavy duty power wheelchair with a patient 
weight capacity 301 to 450 pounds (K0843) and additional items and accessories (codes E1007, E0955, E1028, 
E1012, E2311, E2313, E2377, E2361, E2602, K0108, and E1028).  
You asked the Plan to pre-approve a group 2 heavy duty power wheelchair and additional items and 
accessories. You say that you have made the necessary corrections and updated the chair base to fit for the 
patient's weight. The Plan denied your request. The Plan says the request does not meet the Medicare or health 
plan coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that a PWC is covered if the beneficiarys weight is 
less than or equal to the weight capacity of the power wheelchair that is provided and greater than or equal to 
95% of the weight capacity of the next lower weight class PWC. Medicare rules also say if the base PWC is not 
covered, then related accessories will be denied. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a group 2 heavy duty power wheelchair and additional items and accessories have not been met. 
Specifically, the provided records show that the patient's most recent documented weight is below the required 
weight limit of 301 to 450 pounds for a group 2 heavy duty power wheelchair (K0843). Therefore, we decided 
that the Plan does not have to pre-approve a group 2 heavy duty power wheelchair with a patient weight 
capacity 301 to 450 pounds (K0843) and additional items and accessories (codes E1007, E0955, E1028, E1012, 
E2311, E2313, E2377, E2361, E2602, K0108, and E1028).
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 the requested IRF services to 
regain their maximum function. The Plan denied your request. The Plan says 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 that the complexity of the enrollee's nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care, and can be 
provided in a lower level of care. The enrollee requires treatment by multiple therapies, including physical 
therapy and occupational therapy, but this can be provided in a lower level of care. There is documentation that 
there is a reasonable expectation that this enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF, but the services required can be provided at 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan. 
 
You asked the Plan to pre-approve the PET scan. You say that the requested PET scan is medically necessary. 
The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the 
records do not support the medical necessity of a repeated PET scan. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 the PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found that the record indicates that the enrollee 
has pulmonary nodules in the setting of a history of smoking. The record does not document the presence of 
cancer or the presence of a condition for which coverage is available under the rules. The elements of the 
coverage criteria are not satisfied. The requested service is not 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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for evaluative and therapeutic diagnostic otorhinolaryngologic
services provided on January 10, 2023.

You asked the Plan to pay for these services. 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
diagnosis codes G1221 and Z931 are not among those that are covered for the services rendered.

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, diagnosis codes G1221 and Z931
are not listed as covered diagnosis codes for code 92609. 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
pay for evaluative and therapeutic diagnostic otorhinolaryngologic services provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a LifeAlert telephone alert system. 
 
You asked the Plan to pre-approve a LifeAlert system. You say that you have had instances of falling and have 
been hospitalized as a result. If you fall, you are unable to get back up. The Plan denied your request. The Plan 
says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that telephone alert systems are non-
covered because they are emergency communication systems and do not serve a diagnostic or therapeutic 
purpose. 
 
While this item may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve a LifeAlert telephone alert system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies.  
 
You asked the Plan to pre-approve incontinence supplies. You say that you need these items so you can have a 
better quality of life. The Plan denied your request. The Plan says these items are not covered. 
 
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 incontinence supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ramp to get into the home. 
 
You asked the Plan to pre-approve a ramp. You say that the enrollee needs a handicap ramp due to knee 
arthritis. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
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 ramp to get into the home.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inferior vena cava (IVC) filter to be provided by an out-
of-network (OON) provider.  
 
You asked the Plan to pre-approve inferior vena cava (IVC) filter. You say that the enrollee has IVC filter that 
needs replacement. The Plan denied your request. The Plan says this provider is out-of-network, and the 
services could be performed in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
inferior vena cava (IVC) filter to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve vagus nerve stimulation (VNS). 
 
You asked the Plan to pre-approve vagus nerve stimulation. You say that it is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet the requirements for approval.  
 
The Plan follows Medicare rules. Medicare rules say that FDA approved VNS for treatment of refractory 
epilepsy in 1997 and for resistant depression in 2005. 
 
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 vagus nerve stimulation. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found this is not being used for the 
management of epilepsy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of vagus nerve stimulation. have not been met. Therefore, we decided that the Plan 
does not have to pre-approve vagus nerve stimulation (VNS).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an addition to a lower extremity prosthesis, vertical shock 
reducing pylon (L5988). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the notes do not make any mention of a need for an updated pylon, and makes no 
mention of high impact activities which would warrant the need for an updated pylon. 
 
The Plan must follow Medicare rules. The rules say that coverage is extended only if there is sufficient clinical 
documentation of functional need for the technologic or design feature of a given type of foot. 
 
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 services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that the clinic and physical therapy notes document that the enrollee is at the K3 level. There are 
concrete reasons for the treatment plan specific to the enrollee's high level of function, given that the enrollee 
golfs for exercise. The medical record in this case is therefore more than sufficient on its own merits to approve 
all of the codes originally requested - even if high-impact activity really were a criterium for L5988 coverage, 
which it is not. L5988 can be considered an additional feature/function that may be used in combination with 
L5981, which has already been approved. LCD L33787 specifically requires coverage for L5981 if requested 
for any beneficiary graded at a K3 or higher, but it does not make further stipulations for limiting additional 
features of such a foot. Therefore, the Plans assertion that high-impact activities is part of the coverage 
criteria for L5988 is demonstrably false. The one and only criterium for its coverage flows from a enrollees 
functional level, which is well documented at K3. 
 
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 been met. Therefore, we decided that the Plan has to pre-
approve an addition to a lower extremity prosthesis, vertical shock reducing pylon (L5988).  
 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Hereditary Assessment for Cardiac Conditions and 
Pharmacogenomics Panel provided on May 17, 2023, and billed with codes 81479, 81335, 81238, 81306, 
81291, 81241, 81240, 81238, 81232, 81231, 81227, 81226, 81225, and 81328. 
 
You asked the Plan to pay for the Hereditary Assessment for Cardiac Conditions and Pharmacogenomics 
Panel. You say that this testing was medically necessary. The Plan denied your request. The Plan says this 
testing should be billed with single panel codes. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. These tests were not billed with a single panel code as required. Based on this information, we decided that Medicare rules for coverage of the Hereditary Assessment for 
Cardiac Conditions and Pharmacogenomics Panel have not been met. Therefore, we decided that the Plan does 
not have to pay for the Hereditary Assessment for Cardiac Conditions and Pharmacogenomics Panel provided 
on May 17, 2023, and billed with codes 81479, 81335, 81238, 81306, 81291, 81241, 81240, 81238, 81232, 
81231, 81227, 81226, 81225, and 81328.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device and related 
accessories. 
 You asked the Plan to pre-approve the requested device. You say that the therapy will help healing of throat 
cancer. The Plan denied your request. The Plan says you do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that pneumatic compression devices are only covered 
under certain medical indications.  
 
We looked at the file and Medicare rules. The records do not show that you have lymphedema that extends to 
your chest, trunk, and/or abdomen. The records do not document a trial of a basic (E0651) device. Based on 
this information, we decided that Medicare rules for coverage of the requested device have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device and related 
accessories.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation, nerves innervating the 
sacroiliac joint.  
 
You asked the Plan to pre-approve radiofrequency ablation, nerves innervating the sacroiliac joint. You say that 
this procedure is needed to assist with your pain. The Plan denied your request. The Plan says radiofrequency 
ablation, nerves innervating the sacroiliac joint does not meet the Medicare LCD coverage criteria. 
 
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 radiofrequency ablation, nerves 
innervating the sacroiliac joint. Our reviewer says that the requested radiofrequency ablation, nerves 
innervating the sacroiliac joint is not considered medically reasonable and necessary. Our physician reviewer 
found that radiofrequency ablation, nerves innervating the sacroiliac joint is considered experimental/ 
investigational because of the wide variation in effectiveness 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 radiofrequency ablation, nerves innervating the sacroiliac joint have not been 
met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation, nerves 
innervating the sacroiliac joint.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve DecisionDx-SCC testing (0315U). 
 
You asked the Plan to pre-approve DecisionDx-SCC. You say that this authorization was denied in error. The 
Plan denied your request. The Plan says this test is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. Once this is complete, the test is assigned a 
reimbursement rate and a unique test identifier. 
 
We looked at the file and Medicare rules. This test is listed in the DEX database as non-covered. This 
determination was made and is specific to the test at issue. Based on this information, we decided that 
Medicare rules for coverage of DecisionDx-SCC have not been met. Therefore, we decided that the Plan does 
not have to pre-approve DecisionDx-SCC testing (0315U).