Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve an attended polysomnography (95811). 
 
You asked the Plan to pre-approve an attended polysomnography. You say that your patient should qualify for 
sleep testing, and they meet medical necessity. The Plan denied your request. The Plan says that it is not shown 
that the enrollee has any qualifying comorbid medical conditions, secondary concomitant, chronic opioid use or 
associated sleep disorder other than suspected OSA which would degrade a home sleep test (HST). 
 
The Plan follows Medicare rules. Medicare rules say that a PSG with PAP titration is indicated in patients with 
sleep apnea previously diagnosed by a clinical evaluation and either a positive PSG or a positive HST. 
 
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 attended polysomnography. Our 
reviewer says that the patient meets Medicare criteria for a PAP titration PSG. Our physician reviewer found 
this patient is newly diagnosed Alzheimer's disease, with progressive memory issues and symptoms consistent 
with obstructive sleep apnea.  Attended polysomnography on September 25, 2023, showed mild obstructive 
sleep apnea, with a respiratory disturbance index (RDI) of 5.2. Our reviewer found that an attended PAP 
titration is considered reasonable and medically necessary, because of this patient's Alzheimer's disease and 
memory issues. The patient's dementia may interfere with his ability to initiate auto CPAP on their own at 
home. Our physician reviewer also found that an attended PAP titration study will better meet this patient's 
needs. Medicare rules do not mandate an HST over an attended PSG based on any criteria. 
 
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 attended polysomnography have been met. Therefore, we decided that the 
Plan has to pre-approve an attended polysomnography (95811).  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intraosseous ablation of the basivertebral nerve. 
 
You asked the Plan to pre-approve the intraosseous ablation of the basivertebral nerve. You say that the 
enrollee has tried and failed conservative treatment without relief. The Plan denied your request. The Plan says 
the intraosseous ablation of the basivertebral nerve is considered investigational.  
 
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 intraosseous ablation of the 
basivertebral nerve. Our reviewer says that the intraosseous ablation of the basivertebral nerve is considered 
investigational. Our physician reviewer found that the intraosseous ablation of the basivertebral nerve is 
considered experimental and investigational 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 intraosseous ablation of the basivertebral nerve have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the intraosseous ablation of the basivertebral 
nerve.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided the Plan does not have to provide coverage for an advanced prosthetic foot (L5981 and L5986) for
the enrollee.

You asked the Plan to provide coverage for an advanced prosthetic foot (L5981 and L5986) for the enrollee.
The Plan denied your request. The Plan says Medicare coverage criteria were not met. Maximus overturned the
Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.

The Plan noted the medical records do not show the enrollee is a K3 ambulator. While the physician states that
the enrollee "was expected" to be K3 ambulator, the medical record does not corroborate this. At the time of
the appeal, the medical records show the enrollee was ambulating with a walker and prosthesis. This clinical
information does not support K3 functional ambulation. In addition, the requested equipment is a Blatchford
Endolite Echelon Prosthetic foot, which is a K3 foot. This would be coded as coded as L5981 and L5968 and
should be reviewed as a single unit.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare has specific medical record
documentation requirements for this type of advanced foot. Based on the medical records provided, the
documentation does not show the enrollee was classified as a K3 ambulator at the time of the appeal. The belief
that the enrollee would eventually be a K3 ambulator does not meet the required criteria for approval.
Therefore, we decided that the Plan does not have to provide coverage for an advanced prosthetic foot (L5981
and L5986) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cataract surgery provided on April 25, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for cataract surgery. You say that you should only have a $250 copayment. The Plan 
denied your request. The Plan says services must be provided 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 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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for cataract surgery provided on April 25, 2023, by an 
out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for Positron Emission Tomography (PET) scan for
the enrollee.

You asked the Plan to provide coverage for a PET scan. The Plan denied your request. The Plan says the
Medicare coverage criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen
and stated that Maximus did not apply the correct criteria. The Plan noted that a PET scan is not covered for the
initial staging of melanoma, which is the enrollee's diagnosis.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare does not cover a PET scan for
the initial staging of melanoma. The enrollee's diagnosis was Melanoma. Therefore, we decided that the Plan
does not have to provide coverage for Positron Emission Tomography (PET) scan for the enrollee.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eylea (J0178). 
 You asked the Plan to pre-approve Eylea. You say that the office does not carry Byooviz. You also say that the 
enrollee has received Avastin. The Plan denied your request. The Plan says the enrollee has not tried and failed 
the preferred drugs, Avastin and Byooviz. 
 
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 Eylea. Our reviewer says that the step 
therapy criteria have not been met. Our physician reviewer found the provided documentation does not indicate 
the enrollee has tried and failed the preferred drugs. The reviewer found that there is no documentation 
provided indicating that the Plans required drugs would likely be less effective and/or likely have adverse 
effects for the enrollee. Therefore, the reviewer found that the requested drug Eylea is not medically reasonable 
or necessary as the step therapy criteria have not been 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 Eylea have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Eylea (J0178).
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve the injection, lecanemab-irmb, (Leqembi) (J0174). 
 
You asked the Plan to pre-approve the medication. You say that in hopes of slowing the progression of 
Alzheimer's disease and improving the enrollee's quality of life, the doctor has prescribed Leqembi. The Plan 
denied your request. The Plan says that the enrollee does not meet criteria for approval. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 medication. Our reviewer says that 
the requested items/services is considered medically reasonable and necessary in this case. Our physician 
reviewer found based on the medical records provided and the Medicare-approved major drug compendia there 
is documentation that the Leqembi (lecanemab-irmb) at issue in this case meets all Medicare criteria for 
medically reasonable and necessary for the patient and meets all Medicare criteria for being safe and effective 
for the enrollee. The enrollee in this case has a diagnosis of mild cognitive impairment and dementia consistent 
with Alzheimer's disease with cerebrospinal fluid analysis consistent with the pathological changes of 
Alzheimer's disease. The enrollees depression is reported to be treated, improved and stable. The enrollee is 
reported to be on vitamin B-12 replacement as well as memantine and donepezil.  The enrollee has no evidence 
of apolipoprotein E4 (ApoE4) on testing or cerebral edema or cerebral hemorrhage on imaging. 
 
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 been met. Therefore, we decided that the Plan has to pre-
approve the injection, lecanemab-irmb, (Leqembi) (J0174).  
 
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: 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 rehabilitation services are medically necessary, 
and the enrollee will not be able to receive the required level of continuous clinical oversight at a lower level of 
care. The Plan denied your request. The Plan says the records do not show that the enrollee needs a 
rehabilitation doctor to help with their functional goals.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retainer crowns (D6250) for teeth #2, #4, #6, #7, #8, 
#10 and #11, and pontics (D6240) for teeth #3, #5, and #9. 
 
You asked the Plan to pre-approve D6250 and D6240. You say that you need this dental work. The Plan denied 
your request. The Plan says the medical criteria for this dental work have not been met. 
 
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. The Plan covers D6250 and 
D6240 when the services are medically necessary and reasonable.  
 
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 D6250 and D6240. Our reviewer says 
that this dental work is not medically necessary. Our physician reviewer found a fixed bridge may be 
considered for coverage to replace a single maxillary anterior tooth and if there are no missing posterior teeth in the arch.  In this case there are two missing posterior teeth (#'s 3 and 5) along with missing anterior tooth #9.  
There was no narrative indicating that a removable appliance was contra-indicated. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of D6250 and D6240 have not been met. Therefore, we decided that the Plan does 
not have to pre-approve retainer crowns (D6250) for teeth #2, #4, #6, #7, #8, #10 and #11, and pontics (D6240) 
for teeth #3, #5, and #9.
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 is expected to benefit from 
LTACH and will require at least 25 days. The Plan denied your request. The Plan says an LTACH admission is 
not medically necessary.  
 
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 that the enrollee is improving and only requires short-term acute care at the current 
facility until they are more stable. The enrollee does not require services at the LTACH that are not already 
available at the current facility.  
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.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on February 14, 2023, to 
February 17, 2023, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the services are not payable as 
billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with A41.9, defined as sepsis, unspecified organism. 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 inpatient hospital services at the DRG 
originally billed. Our reviewer says that the documentation does not support the DRG billed. Our physician 
reviewer found the enrollee presented with weakness in the setting of a suspected urinary tract infection (UTI) 
and Parkinsons disease. The enrollee was treated for a UTI and dehydration. There is no evidence that the 
enrollee had sepsis (i.e., hypotension hypoperfusion, organ failure). As such, the billing of A419 is not 
supported.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on February 14, 2023, to February 17, 2023, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on July 14, 2023. 
 
You asked the Plan to pay for the dental services. You say that you needed this dental work. 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 item or service was exhausted on date of service June 13, 2023, and June 
16, 2023. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) 
provided on July 14, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ondansetron tablets. 
 
You asked the Plan to pre-approve Ondansetron tablets. You say that the patient has a history of chronic nausea 
and epigastric/chest pain after meals. 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. Medicare rules say that coverage is extended to oral anti-emetic drugs that are used as full 
replacement for intravenous dosage forms of a cancer regimen under the conditions listed in the Medicare rules 
section of this letter. 
 
Specifically, the oral anti-emetic must either be administered by the treating physician or in accordance with a 
written order from the physician as part of a cancer chemotherapy regimen, the oral anti-emetic drugs 
administered with a particular chemotherapy treatment must be initiated within 2 hours of the administration of 
the chemotherapeutic agent and may be continued for a period not to exceed 48 hours from that time, and/or 
the oral anti-emetic drugs provided must be used as a full therapeutic replacement for the intravenous anti-
emetic drugs that would have otherwise been administered at the time of the chemotherapy treatment. The 
record does not show that this request is being made for any of the covered indications. Therefore, we decided 
that the Plan does not have to pre-approve Ondansetron tablets.  
 
Benefits for Ondansetron tablets 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 Cinvanti. 
 
You asked the Plan to pre-approve Cinvanti. The Plan denied your request. The Plan says the enrollee does not 
have an accepted medical indication.  
 
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 Cinvanti. Our physician reviewer found 
that the enrollee has a diagnosis of breast cancer and is receiving a chemotherapeutic regimen with low 
emetogenic potential. The FDA has not stated that the requested drug is indicated for the enrollee's condition. The Medicare approved cancer drug compendia do not contain a supportive citation for the use of the requested 
drug in the enrollee's clinical situation. No literature from Medicare approved cancer journals were submitted 
for review. 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 Cinvanti have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Cinvanti.