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

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the chest. 
 
You asked the Plan to pre-approve the CT scan. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the CT scan is not medically necessary as it has been only 6-months since 
the last one. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the CT scan. Our reviewer says that the 
CT scan is not medically necessary. Our physician reviewer found you have a sub centimeter pulmonary 
nodule with a negative positron emission tomography (PET) scan that has been stable for over 2 years. This 
does not require a repeat CT scan of the chest at 6-month intervals. This is not recommended nor supported by 
guidelines. 
 
 
 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 CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a computed tomography (CT) scan of the chest.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the genicular nerve block. 
 
You asked the Plan to pre-approve the genicular nerve block. The Plan denied your request. The Plan says the 
genicular nerve block 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 nerve block. Our reviewer 
says that the genicular nerve block is not medically necessary. Our physician reviewer found that the genicular 
nerve block is considered an experimental therapy. 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 genicular nerve block have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the genicular nerve block.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for computed tomography (CT) scans of the head and cervical 
spine provided on July 27, 2023. 
 
You asked the Plan to pay for the CT scans. You say that the services were not related to your hospice 
diagnosis. 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. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 You were under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we 
decided that the Plan does not have to pay for computed tomography (CT) scans of the head and cervical spine 
provided on July 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac joint injection.  
You asked the Plan to pre-approve the injection. You say that the enrollee is in severe pain at times and has to 
make changes to their activities of daily living due to the pain. You say that the enrollee has done a course of 
physical therapy with no help and is currently in massage therapy every 2-3 weeks.  The Plan denied your 
request. The Plan says a sacroiliac joint 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 a 
sacroiliac joint injection is not medically necessary. Our physician reviewer found that there is no 
documentation of a third diagnostic maneuver. 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 a sacroiliac joint injection.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for Vabysmo for the enrollee.

You asked the Plan to provide coverage for Vabysmo. You say that this drug is medically necessary for the
enrollee. The Plan denied your request. The Plan says the required step-therapy criteria are not met. Maximus
overturned the case in error. The Plan requested a reopen and the case was reviewed a second time.

The Plan is correct in this case. 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 preapprove
Vabysmo. Our reviewer says that the required coverage criteria were not met. Our physician reviewer
found at issue is whether Vabysmo for the enrollee is a covered service under Medicare rules. Medicare rules
also allow the plan to use step therapy. This is the process of beginning drug therapy for a medical condition
with "preferred" (or more cost-effective) on-formulary drug alternative(s) and progressing to other drug
therapies only as necessary. A plan must grant an exception to its step therapy rules if it determines that the
requested drug is medically necessary, consistent with the prescriber's statement. The statement must show that
the step therapy drugs have been ineffective in treating the enrollee; or are likely to be ineffective or adversely
affect the drug's effectiveness or patient compliance; or are likely to cause an adverse reaction or other harm to
the enrollee. The Plan requires a trial of Avastin/bevacizumab before they will approve the requested drug.
In this case, the record indicates that the enrollee has proliferative diabetic retinopathy with macular
edema. 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 step-therapy criteria are not shown to be met.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Vabysmo have not been met. Therefore, we decided that the Plan does not have
to provide coverage for Vabysmo for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 36598 billed for date of service August 8, 
2023. 
 
You asked the Plan to pay for the billed service. You say that the service was separate from other codes. The 
Plan denied your request. The Plan says the code is bundled into payment with other services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. We find that CPT code 36598 has a status indicator of T. Code 36598 was billed with other payable services. 
There are payment amounts for code 36598, but they are only paid if there are no other services payable under 
the physician fee schedule billed on the same date by the same provider. Based on this information, we decided 
that Medicare rules for coverage of the billed service have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 36598 billed for date of service August 8, 2023.
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 had a significant decrease in functional 
ability such that they cannot adequately recover in a less intensive setting. The Plan denied your request. The 
Plan says the services the enrollee needs can be provided safely in other settings, for example, a skilled nursing 
facility (SNF).  
 
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 nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical problems are stable and there are no complex nursing or rehabilitation needs. The enrollee does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports a need for 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 the enrollee 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: 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 requires an IRF level of care. The Plan 
denied your request. The Plan says an IRF admission 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 does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record supports a need for multiple therapies, including physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. There is not 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. Medically necessary care can be provided in a different 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on August 1, 
2023. 
 
You asked the Plan to pay for periodontal maintenance (D4910). You say that you have a special need for this 
specific type of cleaning. You also say you cannot have a regular type of cleaning. The Plan denied your 
request. The Plan says this service is not covered under your dental benefit. 
 
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. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
periodontal maintenance (D4910) provided on August 1, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for resin-based composite - three surfaces, anterior (D2332) and 
pin retention (D2951) provided on July 6, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your benefit for the resin-based composite has already been exhausted. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the resin-based composite was exhausted on date of service April 7, 2023. Pin retention 
is not a covered service. Therefore, we decided that the Plan does not have to pay for resin-based composite - 
three surfaces, anterior (D2332) and pin retention (D2951) provided on July 6, 2023.
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 services are medically necessary for you to get 
better and return home. The Plan denied your request. The Plan says you do not meet the criteria for admission 
to an IRF.  
 
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 you do not require treatment by multiple therapies. While the medical record 
supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing (87481, 87491, 87496, 87529, 87563, 
87591, 87640, 87661, 87556, and 87798) provided on June 20, 2023. 
 
You asked the Plan to pay for the panel testing. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.   
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the panel testing (87481, 87491, 87496, 87529, 87563, 87591, 87640, 87661, 
87556, and 87798) provided on June 20, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tint photochromatic lenses and the frames provided on 
May 20, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the tint photochromatic lenses and the frames. You say that you are resubmitting 
legible reimbursement documentation. The Plan denied your request. The Plan says the provider was out-of-
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
tint photochromatic lenses and the frames. We found no exception that would require the Plan to pay for the 
tint photochromatic lenses and the frames. Therefore, we decided that the Plan does not have to pay for the tint 
photochromatic lenses and the frames provided on May 20, 2023, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral periapical x-ray (D0220) and each additional 
periapical x-rays (D0230x3) provided on July 24, 2023. 
 
You asked the Plan to pay for the dental services. You say that you had this x-ray done in January before a 
tooth repair. You say the doctor's office has never seen insurance deny subsequent routine x-rays due to this 
situation. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
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. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested services were exhausted on date of service January 23, 2023. Therefore, 
we decided that the Plan does not have to pay for the intraoral periapical x-ray (D0220) and each additional 
periapical x-rays (D0230x3) provided on July 24, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health physical therapy. 
 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 based on the 
available records the enrollee appears to have improved with therapy to the point of being able to manage gait 
and transfers independently and she has met her short-term and long-term goals for most left shoulder 
movements. After the therapy treatments already provided, records do not support that the complexity of the 
enrollees conditions are such that the skills of a professional therapist are required to achieve further 
improvement in the enrollee's symptoms or functional status. Further utilization of the home exercise program 
appears appropriate at this point. 
 
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 physical therapy.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing provided on April 11, 2023, billed with 
codes 81225, 81226, 81227, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 81335, 81479, and 81238. 
 
You asked the Plan to pay for the testing billed. You say that medical records were provided. The Plan denied 
your request. The Plan says there is no documentation how the results will impact treatment. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
The file shows that a combined cardio and pharmacogenetic test panel was provided. We looked at the file and 
Medicare rules. This NGS panel was not billed with a single panel code as required. Additionally, the medical 
records do not show that the testing was ordered for a specific medical condition. Medications should be 
provided based on the presence of a diagnosis and should be adjusted based on a response to the medication. 
Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pay for the panel testing provided on April 11, 2023, billed with codes 
81225, 81226, 81227, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 81335, 81479, and 81238.