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

 
We decided that the Plan does not have to pre-approve Ilumya. 
 You asked the Plan to pre-approve Ilumya. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
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 Ilumya. Our reviewer says that the 
documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found the enrollee has psoriasis. The documentation does not support that the enrollee has tried and 
failed Adalimumab, Rinvoq, Skyrizi, Actemra, Cosentyx, Otezla, Xeljanz, Xeljanz XR, Orencia or Enbrel. The 
documentation does not support that Adalimumab, Rinvoq, Skyrizi, Actemra, Cosentyx, Otezla, Xeljanz, 
Xeljanz XR, Orencia or Enbrel would likely be less effective and/or likely have adverse effects for the enrollee. 
Therefore, the enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Ilumya have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Ilumya.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99221) provided on January 11, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment is included in 
the global surgery payment. 
 The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery..  
 
We looked at the file and Medicare rules. Payment for the requested services (99221) is included in the global 
surgery payment for the procedure (21320) provided on the same date of service. 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 pay for the services (99221) provided on January 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac joint injection (27096). 
 
You asked the Plan to pre-approve sacroiliac joint injection. You say that the provided records support the 
necessity of the requested service. The Plan denied your request. The Plan says the sacroiliac joint injection 
requested does not meet the requirements for approval. 
 
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 sacroiliac joint injection. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has a history of chronic low back pain and has been treated with 
medications, physical therapy, spinal cord stimulator placement, and previous surgical procedures, most 
recently an L3-L4 fusion on July 19, 2022.  The enrollee had bilateral sacroiliac joint (SIJ) injections on May 26, 2022.  The response to treatment was not documented. The enrollee was evaluated in the office on October 
26, 2022, with low back pain with radiation into the buttocks. In this case, there is no documentation on 
physical examination of three (3) or more positive tests results. The clinical value and effectiveness of an SI 
joint injection in the absence of tenderness and negative provocative testing results have not been demonstrated 
in the peer-reviewed literature. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of sacroiliac joint injection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve sacroiliac joint injection (27096).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Power Pride Go-Go motorized scooter. 
 
You asked the Plan to pre-approve a motorized scooter. You say that it is difficult for the enrollee to walk long 
distances. The Plan denied your request. The Plan says that the enrollee was provided a bariatric scooter in 
May 2023 for their mobility needs. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that the enrollee has a bariatric scooter. A bariatric scooter serves the same purpose as a 
motorized scooter. Therefore, we decided that the Plan does not have to pre-approve a Power Pride Go-Go 
motorized scooter.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the percutaneous implantation of neurostimulator 
electrode array, epidural (63650). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says your request is not medically necessary because the enrollee's records show 
that the enrollee does not meet the criteria. The Plan states the enrollee has not tried interventional pain 
injections for the enrollee's active diagnoses of facet-mediated pain or the enrollee's sacroiliac joint mediated 
pain. The Plan states there is not notation of evaluation by a surgeon, nor recent physical therapy; thus, this 
device is not being used as a late or last resort for treatment of the enrollee's pain. 
 
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 service. Our physician reviewer 
found spinal cord stimulation (SCS) is a late/ last resort. The enrollee has other evidence-based interventions 
available. The request does not meet the LCD criteria. The request is deemed not medically reasonable and 
necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the percutaneous implantation of neurostimulator electrode array, epidural (63650).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for definitive drug testing (G0483) billed for date of service 
September 1, 2022. 
 
You asked the Plan to pay for drug testing. You say that this service was necessary and is supported as billed. 
The Plan denied your request. The Plan says the code used to report the services provided is not supported in 
the medical record. 
 
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, the CPT Code Manual definition of code G0483 is drug test(s), definitive, 22 or more drug 
class(es), including metabolite(s) if performed. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the records support that 
drugs from 6 classes were tested in this case. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for 
definitive drug testing (G0483) billed for date of service September 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We have decided to dismiss the Plan's request to reopen the case because it does not meet Medicare rules for a reopening. The Plan submitted their own physician review of this case in which they disagree with our decision. The Plan states the enrollee does not meet all of the required criteria.
We have reviewed the information that the Plan submitted. When an appeal is received at this level, Maximus sends out acknowledgement letters to all parties to the appeal which gives those parties a chance to submit additional information. Your office submitted additional information in support of your appeal. Maximus is not obligated to send that information to the Plan to allow them a third chance to review the appeal. Based on the information submitted, our Physician determined the required criteria were met. Distinguished physicians may sometimes disagree over the appropriate course of treatment for a particular patient at a given point in time. That disagreement is not necessarily a valid reason to reopen a case. We find no evidence of error in this case and we are therefore dismissing the request to reopen. Our decision remains that the Plan has to provide coverage for the Freestyle Libre 14-day sensor kit.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the percutaneous laminotomy/laminectomy 
(interlaminar approach) for decompression of neural elements, (with or without ligamentous resection, 
discectomy, facetectomy and/or foraminotomy), any method, under indirect image guidance (eg, fluoroscopic, 
CT), single or multiple levels, unilateral or bilateral; lumbar (0275T). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the service is not 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 service. Our physician reviewer 
found the NCD only covers this requested procedure for enrollees who are currently enrolled in an approved 
study. This is not evident. No compelling rationale is presented, or extenuating circumstances noted to support 
the medical necessity of this request as an exception. Therefore, the medical records provided do not meet the requirements listed in the NCD for Medicare coverage. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the percutaneous laminotomy/laminectomy (interlaminar approach) for decompression of 
neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy), any 
method, under indirect image guidance (eg, fluoroscopic, CT), single or multiple levels, unilateral or bilateral; 
lumbar (0275T).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 6 office visits. 
 
You asked the Plan to pre-approve outpatient visits. You say that the requested visits are medically necessary 
to further the enrollee's treatment. The Plan denied your request. The Plan says the requested office visits can 
be provided in-network. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet the enrollees needs. The enrollees contract with the Plan says that, with few 
exceptions, enrollees must use contract providers for care.  
 
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 outpatient visits. Our reviewer says that 
the request for additional out-of-network visits is not medically necessary. Our physician reviewer found the 
documentation does not demonstrate any unique features of the enrollees condition that would necessitate 
continuity of care with the out-of-network provider. The reviewer found that the enrollee has peripheral artery 
disease (PAD) and was last seen approximately 9 months ago. The current provider has not performed any type 
of complex surgery nor is providing any active treatment that would necessitate continuity of care. The 
reviewer also found that the enrollee's health plan has provided two vascular surgeons in-network that care can 
be transitioned to. Therefore, the reviewer found that the requested visits are 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 outpatient visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an additional 6 office visits.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Pirfenidone Capsules.

You asked the Plan to pre-approve Pirfenidone Capsules. You say that the medication is necessary for the enrollee's health and wellbeing. The Plan denied your request. The Plan says the medication is not covered as a medical benefit under the Plan.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Pirfenidone Capsules.

Benefits for Pirfenidone Capsules 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the admission is medically 
necessary. The Plan denied your request. The Plan says the procedure is currently approved as an ambulatory 
procedure. The reason for the requested inpatient admission is for physical therapy evaluation and 
neuropsychological testing. These services can be done on an outpatient/observation basis. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient hospital care is not met in 
this case. Our physician reviewer found the request for lumbar puncture was approved by the health plan 
during the initial organization determination review. This enrollee has NPH. The planned procedure listed 
under CPT code 62272 is not listed on the CMS Inpatient Only List. The procedure is currently approved as an 
ambulatory procedure. The reason for the requested inpatient admission is for physical therapy evaluation and 
neuropsychological testing. These services can be done on an outpatient/observation basis. The review 
indicates that the record does not show that at the time of inpatient admission the admitting physician 
reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or observation care) 
would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (K0861) and accessories. 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that the requested PWC and 
accessories are medically necessary. The Plan denied your request. The Plan says the requested items are not 
medically necessary. 
 
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 a power wheelchair and accessories. 
Our reviewer says that the coverage criteria has not been met. Our physician reviewer found that the enrollee 
has a neurologic disorder with functional deficits. The documentation does not indicate that the enrollee has 
any pressure injuries or requires intermittent catheterization of the bladder or has spasticity that would 
necessitate power tilt or recline. Although the enrollees condition may meet criteria for a PWC, the criteria for 
this specifically requested PWC with multiple power options including power tilt and recline are not met. 
Considering the requested PWC base is not medically necessary, the requested accessories are not covered. 
 
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 power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a Group 3 power wheelchair (K0861) and accessories.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 You asked the Plan to pre-approve Prolia. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
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 Prolia. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has a diagnosis of age-related osteoporosis without current pathological fracture. The 
documentation does not support that the enrollee has tried and failed a generic oral bisphosphonate (such as 
alendronate, risedronate, or ibandronate). The documentation does not support that generic oral bisphosphonate 
(such as alendronate, risedronate, or ibandronate) would likely be less effective and/or likely have adverse 
effects for the enrollee. Therefore, the enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: ER
Decision: Unfavorable

We decided the Plan does not have to reduce the $195 copayment for observation services provided on September 14, 2022.
You asked the Plan to reduce this copayment. You say these were emergency room services and should be $75. The Plan denied your request. The Plan says the medical records show you were treated under observation status. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct contract criteria.
The Plan is correct in this case. The Plan follows Medicare rules. The rules say the Plan contract must clearly state what you can expect to pay for services provided. The contract states observation care has a copayment of $195. The medical records show you were provided with observation services and the claim was billed with observation services.
You have been asked to pay the correct copayment based on the services provided and the Plan contract agreement. Therefore, the Plan is not required to reduce the $195 copayment for observation services provided on September 14, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a single photon emission computed tomography 
(SPECT) for the diagnosis of Parkinson's disease. 
 
You asked the Plan to pre-approve a single photon emission computed tomography (SPECT). You say that a 
single photon emission computed tomography (SPECT) for the diagnosis of Parkinson's disease is medically 
necessary. The Plan denied your request. The Plan says a single photon emission computed tomography 
(SPECT) for the diagnosis of Parkinson's disease is not covered by Medicare or by the Plan. 
 
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 a single photon emission computed 
tomography (SPECT). Our reviewer says that the requested single photon emission computed tomography 
(SPECT) is not considered medically reasonable and necessary in this case. Our physician reviewer found that 
in this case the enrollee is suspected of possibly having a synucleinopathy per the notes provided for review. 
The enrollee had features/symptoms consistent with such a condition. However, the records provided for 
review did not otherwise indicate the presence of any findings on physical/neurological examination to readily 
support a diagnosis of Parkinson's disease (PD). A DaT Scan's formal utility is otherwise to rule in a diagnosis 
of Parkinson's disease. Given that PD is not suspected in this case, it cannot readily be said that the use of this 
service would be consistent with standards of practice/care. Medical necessity is unable to be established at this 
time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a single photon emission computed tomography (SPECT) have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a single photon emission computed 
tomography (SPECT) for the diagnosis of Parkinson's disease.