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

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the enrollee would benefit from this. 
The Plan denied your request. The Plan says the available scientific evidence does not support conclusions 
regarding safety, effectiveness, and met outcomes for an Intracept procedure. 
 
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 an Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no magnetic resonance imaging (MRI) showing only modic changes without 
facet joint disease or stenosis. Also, the cause of pain not clear. 
 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
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 stable and suitable for 
transfer to an LTACH. You say that the enrollee cannot be adequately care for in their current condition at a 
lower level of care. 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 does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. The plan has approved ongoing care in the current 
acute care setting. 
 
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: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve treatment of the enrollee's left eye with Izervay. 
 
You asked the Plan to pre-approve Izervay for the left eye. You say that the requested treatment is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says that the enrollee's left eye does not meet 
criteria for treatment with Izervay. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Izervay for the left eye. Our reviewer 
says that Izervay for the left eye is medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee has a diagnosis of bilateral nonexudative age-related macular degeneration 
with geographic atrophy. The FDA has stated that the requested drug is indicated for the enrollee's condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Izervay for the left eye have been met. Therefore, we decided that the Plan has 
to pre-approve treatment of the enrollee's left eye with Izervay.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve carboplatin, Abraxane and Keytruda. 
 
You asked the Plan to pre-approve the medications. You say that the enrollee responded so well to this 
combination you stopped the chemotherapy. Unfortunately, Keytruda for maintenance was not enough.  The 
Plan denied your request. The Plan says the requested use of this drug combination is not supported. 
 
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 the medications. Our reviewer says that 
the requested use of carboplatin, Abraxane and Keytruda is not FDA approved for the enrollees diagnosis. Our 
physician reviewer found that the use of carboplatin, Abraxane and Keytruda is also not supported by one of 
the major drug compendia or by clinical research. 
 
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 medications have not been met. Therefore, we decided that the Plan does 
not have to pre-approve carboplatin, Abraxane and Keytruda.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator system. 
 
You asked the Plan to pre-approve a home ventilator system. You say that without the machine the enrollee is 
at a higher risk of other health issues. The Plan denied your request. The Plan says a home ventilator is not 
medically necessary for this patient because their needs can be met with an alternative device such as a BiPAP 
device with average volume-assured pressure support (AVAPS).   
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not 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 a home ventilator system. Our reviewer 
says that a home ventilator system is not medically necessary. Our physician reviewer found that the enrollee 
has chronic hypercapnic respiratory failure from obstructive sleep apnea with presumed restrictive physiology 
and are being treated with a BiPAP. However, there is no sufficient detailed information in the medical records 
to justify the treatment selected. Furthermore, the enrollee can be treated with a BiPAP machine with AVAPS 
capability and failure of such a device has not been documented. Therefore, the elements of the coverage 
criteria are not satisfied, and 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 a home ventilator system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a home ventilator system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection.  
 
You asked the Plan to pre-approve the injection. You say that the pain starts in the enrollee's back and radiates 
down bilateral anterior thighs to toes, and its worse with activity and movement. You say that the last bilateral 
L5-S1 transforaminal epidural steroid injection was on June 13, 2023, with reports of 80-90% pain relief with 
improvement for function for five months. The Plan denied your request. The Plan says an epidural steroid 
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 an 
epidural steroid injection is not medically necessary. Our physician reviewer found that the records do not how 
that the last epidural steroid injection on June 1, 2023, provided at least 50% pain relief for at least three 
months. Therefore, the epidural steroid injection is considered 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 an epidural steroid injection.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the percutaneous vertebral augmentation (PVA) (22310) 
provided on April 26, 2023. 
 
You asked the Plan to pay for the PVA. You say that you paid $1,415 out-of-pocket for this service. You also 
say that this needs to be reprocessed and paid. The Plan denied your request. The Plan says this procedure was 
not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that percutaneous vertebral augmentation (PVA or 
kyphoplasty) will be considered reasonable and necessary for osteoporotic conditions when an acute or 
subacute osteoporotic vertebral compression fracture (VCF) is present. 
 
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 PVA. Our reviewer says that the PVA 
was not medically necessary. Our physician reviewer found the detailed documentation is not evident regarding 
an acute or subacute compression fracture at L1. Formal diagnostic studies are not provided. Additionally, 
there is no documentation of a progression of the body height loss, kyphotic deformity, or a severe impact on 
daily activities. Moreover, there is magnetic resonance imaging (MRI) corroboration of retropulsion and other 
plausible causes of pain. Therefore, the reviewer found that the percutaneous vertebral augmentation (PVA) 
was 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 the PVA have not been met. Therefore, we decided that the Plan does not have 
to pay for the percutaneous vertebral augmentation (PVA) (22310) provided on April 26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (87491 and 87640) billed for date of 
service July 17, 2023. 
 
You asked the Plan to pay for laboratory services. You say that this testing was necessary and is supported in 
the medical record. The Plan denied your request. The Plan says the records provided do not include a 
physician order to support the necessity of these services. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of laboratory services have been met. 
Specifically, the medical records provided do not include a physician order for this testing, or any physician 
notes or medical records to support that a physician who is treating the enrollee intended to have these tests 
performed. Therefore, we decided that the Plan does not have to pay for laboratory services (87491 and 87640) 
billed for date of service July 17, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept procedure. You say that this procedure would benefit the 
enrollee. The Plan denied your request. The Plan says the requested procedure 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 an Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found documentation does not support actual formal surgical ablation of pre-designated 
basivertebral nerves as being medically necessary and/or reasonable at this time. There is also no compelling 
rationale presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception.   
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve iovera procedure of the left knee. 
 
You asked the Plan to pre-approve iovera procedure of the left knee. You say that you are requesting 
reconsideration for the denied claim. The Plan denied your request. The Plan says Medicare does not cover 
experimental services, items, and medications. 
 
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 iovera procedure of the left knee. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found you were recommended to undergo cortisone injections as well as 
viscosupplementation injections on October 26, 2023 examination without any noted follow-up to indicate if 
these injections had been tried and failed. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested 
iovera procedure to the left knee is not medically reasonable or necessary.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of iovera procedure of the left knee have not been met. Therefore, we decided that 
the Plan does not have to pre-approve iovera procedure of the left knee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat percutaneous right sacroiliac joint fusion. 
 
You asked the Plan to pre-approve a percutaneous right sacroiliac (SI) joint fusion. You say that the enrollee 
would benefit from this. The Plan denied your request. The Plan says there are no imaging studies of the right 
sacroiliac joint to demonstrate any signs of hardware failure or complication. 
 
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 percutaneous right sacroiliac (SI) joint 
fusion. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found there is no SI joint instability, fracture, or lesion. SI joint 
fusion for degenerative back pain is experimental. 
 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 percutaneous right sacroiliac (SI) joint fusion have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a repeat percutaneous right sacroiliac joint fusion.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that you cannot breathe unless you are on a machine and 
are a fall risk due to lack of oxygen. You say that you need rehabilitation level of care. The Plan denied your 
request. The Plan says you do not meet Medicare criteria for SNF care, and your needs can be met at a lower 
level of care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on July 17, 2023. 
 
You asked the Plan to pay for the ambulance services. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says two of the billed diagnosis codes cannot be 
reported together. 
 
The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other diagnosis codes with which they cannot be reported.  
 
In this case, we have confirmed that J96.10 has an Excludes1 note in relation to R06.02. This means that the 
two diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare 
billing rules for the ambulance services have not been met. Therefore, we decided that the Plan does not have 
to pay for ambulance services provided on July 17, 2023.  
 
Please note- our decision is limited to the claim that was actually denied by the Plan.  If you have since 
submitted a corrected claim, any questions regarding that corrected claim should be sent to the Plan directly.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health care provided to the enrollee from June 24,
2022, to July 23, 2022.

You asked the Plan to pay for the home health care. You say that the home health care was necessary. The Plan
denied your request. The Plan says the NOA was not received timely. As such, this final claim was correctly
denied. Maximus overturned the Plan's denial. The Plan requested a reopening and stated that there is no proof
that the NOA was submitted timely. The Plan is correct in this case. The proof that was submitted is an internal
form and does not show that the NOA was sent to the Plan before the submission date of September 26, 2022,
that the Plan has on file.

The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of
care date for home health services. NOAs which are received more than 30 days from the timely filing date
result in no payment being made for the episode of care.

In this case, the start of care date is June 24, 2022. The NOA was not received by the Plan until September 26,
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health care provided
to the enrollee from June 24, 2022, to July 23, 2022.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the second magnetic resonance imaging
(MRI) provided on March 14, 2023.

You asked the Plan to waive the copayment for the second MRI. You say that you are getting billed twice for
the same service. The Plan denied your request. The Plan says this cost sharing was charged correctly.
Maximus overturned the Plan's denial. The Plan requested a reopening and stated that you were responsible for
a copayment for each MRI received. The Plan is correct in this case. The case file indicates you had two MRIs
on this date of service. One on your left leg and one on your right leg. Your contract with the Plan clearly says
that you must pay a $75 copayment for each Medicare-covered MRI, MRA, and Angiogram at a freestanding
provider.

You have been asked to pay a $75 copayment for the second MRI. This item/service falls within the Medicarecovered
MRI, MRA, and Angiogram at a freestanding provider benefit category. This means that you have
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have
to waive the copayment for the second magnetic resonance imaging (MRI) provided on March 14, 2023.