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

 
We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation (22514).  
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of the 
requested service.  
 
The Plan follows Medicare rules. Medicare rules say that percutaneous vertebroplasty or kyphoplasty is 
covered in patients with both of the indicated criteria.  
 
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 this service. Our reviewer says that the 
enrollee does not meet criteria for coverage of the requested service. Our physician reviewer found that the 
enrollee was being treated for a compression fracture of the L1 vertebra with delayed healing. He presented 
with pain rated at 7-8/10. He was originally seen for a possible kyphoplasty at L1. The magnetic resonance 
imaging revealed an L1 compression fracture, scoliosis, spondylosis, and spondylolisthesis at L4-5. He was 
required to pursue physical therapy prior to the procedure. He received no relief with physical therapy. He still 
experiences axial and left-side low back pain with no radiation. The exam reveals tenderness to palpation over 
the lumbar region. There is pain on flexion/extension of the lumbosacral spine. 
 
However, detailed documentation is not evident regarding the L1 compression fracture being acute or subacute.  
There is no documentation of osteoporosis or treatment for osteoporosis. Additionally, there is no 
documentation of a progression of the body height loss, worsening pain, 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 enrollee does not meet Medicare criteria for coverage of this 
service.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous vertebral augmentation (22514).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar facet ablation. 
 
You asked the Plan to pre-approve lumbar facet ablation. You say that you are in intense pain and need the 
injection. The Plan denied your request. The Plan says the enrollee does not meet the criteria for this. 
 
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 lumbar facet ablation. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found the LCD criteria requires 80% 
pain relief. this was not achieved and therefore, the request is deemed not medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lumbar facet ablation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve lumbar facet ablation.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for in-network botox injections provided on 
September 28, 2023. 
 
You asked the Plan to reduce the coinsurance for in-network botox injections. You say that you have had this 
done before and it was almost a $0 cost. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for in-network botox injections. This item/service falls within the 
Medicare Part B prescription drugs 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. The total you owe is $511.20 ($2,556 x 20% = $511.20). Therefore, we decided 
that the Plan does not have to reduce the coinsurance for in-network botox injections provided on September 
28, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve selective catheter placement, arterial system; initial third 
order or more selective abdominal, pelvic, or lower extremity artery branch, within a vascular family (36247). 
 
You asked the Plan to pre-approve bilateral genicular artery embolization. You say that this is medically 
necessary. The Plan denied your request. The Plan says this is not medically necessary because based on the 
medical literature this procedure is not considered standard of care for management of your chronic knee pain. 
 
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 bilateral genicular artery embolization. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found there is limited published, large-scale, long-term peer-reviewed 
literature that shows this request to be an effective and/or safe treatment for the noted pathology. While the 
studies are noted to be promising, further studies/research is needed to corroborate that geniculate artery 
embolization is as good as or better than standard treatments for knee osteoarthritis. No compelling rationale is 
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 bilateral genicular artery embolization have not been met. Therefore, we 
decided that the Plan does not have to pre-approve selective catheter placement, arterial system; initial third 
order or more selective abdominal, pelvic, or lower extremity artery branch, within a vascular family (36247).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve stab phlebectomy (37765). 
 
You asked the Plan to pre-approve stab phlebectomy. You say that this is medically necessary. The Plan denied 
your request. The Plan says saphenous reflux is present and there is no information on the size of tributaries to 
be treated. 
 
The Plan follows Medicare rules. Medicare rules say that stab phlebectomy can be covered when specific 
criteria are met. 
 
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 stab phlebectomy. Our reviewer says 
that the enrollee does not meet criteria for coverage. Our physician reviewer found as the patient has not yet 
undergone saphenous vein reflux treatment, criteria have not been met.  Additionally, review of the assessment 
and plan does not specify that stab phlebectomy was planned or required. The health plan does not provide for 
simultaneous saphenous reflux treatment and tributary treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of stab phlebectomy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve stab phlebectomy (37765).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Pembrolizumab and Paclitaxel. 
 
You asked the Plan to pre-approve Pembrolizumab and Paclitaxel. You say that the medications are medically 
necessary. The Plan denied your request. The Plan says the medications are not medically necessary. 
 
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 Pembrolizumab and Paclitaxel. Our 
reviewer says that the medications are not medically necessary. Our physician reviewer found there is no PD-
L1 score provided in the documents received. The use of Pembrolizumab and Paclitaxel is not supported by 
one of the major drug compendia or by clinical research. The requested medications cannot be approved. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Pembrolizumab and Paclitaxel. have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Pembrolizumab and Paclitaxel.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on March 13, 2023.

You asked the Plan to pay for these services. The Plan denied your request. The Plan says the Medicare billing
criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and provided
additional information. The Plan noted that the claim was billed with a place of service (POS) code of 81, for
Independent Laboratory, independent of an institution or a physician's office. An independent laboratory taking
a sample in its laboratory shows "81" as place of service. The difference between the collection date/time and
the received date/time confirms that this was not taken by the laboratory directly. Therefore, this claim POS
code of 81 was billed in error.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. In this case this claim could not be paid as billed due to an error with POS code
reported.

Medicare rules for payment of these services have not been met. Therefore, we decided that the Plan does not
have to pay for lab services provided to the enrollee on March 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI).  
 
You asked the Plan to pre-approve SSBCI benefits. You say that you have heart failure. You also say you were 
told it is a chronic condition. The Plan denied your request. The Plan says the criteria for eligibility have not 
been met.  
 
  The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an 
eligible condition that meets all the required criteria. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance treatment without transport provided on April 29, 
2023. 
 
You asked the Plan to pay for the ambulance treatment without transport. You say that you fell and were 
unable to get up without assistance. You did not need to go to the hospital. The Plan denied your request. The 
Plan says the Medicare ambulance benefit is a transportation benefit and without a transport there is no payable 
service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on April 29, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance treatment without transport provided 
on April 29, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance treatment without transport provided on August 
13, 2023. 
 
You asked the Plan to pay for the ambulance treatment without transport. You say that the paramedics were 
called without your knowledge, but you did not need to go to the hospital. The Plan denied your request. The 
Plan says the Medicare ambulance benefit is a transportation benefit and without a transport there is no payable 
service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on August 13, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance treatment without transport provided 
on August 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided by a chiropractor on September 6, 
2023. 
 
You asked the Plan to pay for the office visit. You say that you desperately need this service to provide you 
some relief while you wait to have surgery for the severe pain. The Plan denied your request. The Plan says the 
only covered chiropractic service is manual manipulation of the spine. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit provided by a chiropractor on September 6, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on September 01, 2023. 
 
You asked the Plan to pay for psychotherapy. You say that the services were medically necessary. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for psychotherapy provided 
on September 01, 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 IRF care is necessary. The Plan denied your request. 
The Plan says the criteria for IRF care are not met.  
 
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 your nursing, medical, and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the medical records support a need for physical and/or occupational 
therapy, there is no documented need for intensive rehabilitation services. There is not a reasonable expectation 
that you 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on July 07, 2023. 
 
You asked the Plan to pay for a home visit. You say that the provider was not responsible for obtaining 
authorization. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a home visit provided on 
July 07, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergency ambulance transportation. provided on 
August 11, 2023. 
 
You asked the Plan to pay for non-emergency ambulance transportation.. You say that the service was 
medically necessary. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for non-emergency 
ambulance transportation. provided on August 11, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a privacy flap wheelchair accessory. 
 
You asked the Plan to pre-approve a privacy flap wheelchair accessory. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says a privacy flap wheelchair accessory is not 
covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a privacy flap wheelchair accessory.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy to be provided by an OON provider.  
 
You asked the Plan to pre-approve physical therapy. You say that the requested physical therapy services are 
medically necessary. The Plan denied your request. The Plan says the enrollee must receive their care from a 
network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
physical therapy to be provided by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve revascularization, endovascular, open or percutaneous,
iliac artery, unilateral, initial vessel; with transluminal stent placement(s), includes angioplasty within the same
vessel, when performed (37221) of the right side for the enrollee.

You asked the Plan to pre-approve these services. You say that this procedure is medically necessary. The Plan
denied your request. The Plan says that the site of the blockage must be more than 50 percent.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for revascularization
services. Our Medical Director states that the enrollee has bilateral lower extremity peripheral arterial disease.
It is documented that the enrollee underwent a left lower extremity angiogram on October 19, 2020. The left
iliac artery was unable to be angioplastied and remained occluded. A right lower extremity angiogram was
performed on October 26, 2020. The enrollee had critical stenosis/occlusion of the right proximal superficial
femoral artery. Atherectomy, stent, and angioplasty of the iliacs and superficial femoral arteries resulted in
resolution of the stenosis on the right. On May 24, 2023, the enrollee was advised that a right lower extremity
angiogram was needed to evaluate for iliac stenosis and occlusion, and that he would likely require a right to
left fem-fem bypass. The documentation does not support that revascularization, endovascular, open or
percutaneous, iliac artery, right unilateral, initial vessel; with transluminal stent placement(s), includes
angioplasty within the same vessel, when performed (37221), was medically reasonable and necessary for the
enrollee in this case. Our Medical Director found that the enrollee's condition does not meet criteria for
coverage of these services.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial
vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed
(37221) of the right side for the enrollee.