Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rituxan. You asked the Plan to pre-approve Rituxan. 
You say that the requested drug is medically necessary. The Plan denied your request. The Plan says you must 
provide documentation that the enrollee has tried all the Plan's preferred medicine (trial of Ruxience or Truxima) and that did not help or that the notes show that it is expected that Rituxan will work better for the 
enrollee's condition than the preferred medicine(s) or that the enrollee may have a specific medical reason why 
the preferred medicine(s) cannot be used for their care, or the enrollee has taken Rituxan for their condition 
within the past year and their provider has prescribed continued use of Rituxan for their care.  
 
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 Rituxan. Our reviewer says that the 
requested drug is not medically necessary. Our physician reviewer found that the Plan requires a trial of the 
drug Ruxience or Truxima before they will approve the requested drug. In this case, the enrollee has not tried 
and failed the required drug(s). There is no documentation provided indicating that the Plans required drug(s) 
would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Rituxan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Rituxan.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 6 skilled nursing visits. 
  You asked the Plan to pre-approve home health services. You say that the home health visits are medically 
necessary. The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found you have been 
medically stable without any recent exacerbations of chronic medical problems or hospitalizations. Additional 
skilled nursing services are not required to effectively provide treatment to improve your condition or perform 
a maintenance program to maintain your condition or prevent deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 6 skilled nursing visits.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the heart for 
calcium scoring. 
 
You asked the Plan to pre-approve the CT scan. You say that the scan is medically necessary. The Plan denied 
your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the CT scan. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found guidelines recommend CT scan for calcium 
scoring only when patients are at intermediate risk to help determine if statin therapy is reasonable or 
warranted. In this case, statin therapy is already warranted, and the CT scan would not add any new 
information that would change this patient's risk category or lead to any improved outcome. 
 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a computed tomography (CT) scan of the heart for calcium scoring.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the spring powered device (A4258) provided to the enrollee
on July 20, 2022.

You asked the Plan to pay for the spring powered device. You say that you feel this should be covered. The
Plan denied your request. The Plan says that this cannot be provided more than once every six months.
Maximus overturned the Plan's denial based on a lack of information. The Plan requested a reopening and
stated that this can only be covered once every 6 months. The Plan is correct in this case. Medicare rules state
that more than one spring powered device (code A4258) per 6 months is not reasonable and necessary. The
Plan provided documentation showing they paid for a spring powered device on May 17, 2022, which is less
than 6 months from July 20, 2022. Based on this information, we decided that Medicare rules for coverage of
the spring powered device have not been met. Therefore, we decided that the Plan does not have to pay for the
spring powered device (A4258) provided to the enrollee on July 20, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve a consultation at the out-of-network provider. 
 
You asked the Plan to pre-approve a consultation at the out-of-network provider. You say that you have seen 
this provider before. The Plan denied your request. The Plan says that the requested services can be provided 
by a network provider. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
We looked at the file and Medicare rules. Review of the file shows that the Plan has advised you to see the in-
network provider. This in-network provider is 38.93 miles (49 minutes) away from your home. The maximum 
distance Medicare approved travel is 30 miles or 45 minutes. This in-network provider exceeds the Medicare 
approved travel and therefore, you should not be expected to see this in-network provider that exceeds the 
approved travel distance/time. No other approved provider information was provided by the Plan. The Plan did not substantiate their denial. Based on this information, we decided that Medicare rules for coverage of a 
consultation at the out-of-network provider have been met. Therefore, we decided that the Plan has to pre-
approve a consultation at the out-of-network provider.  
 
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 pay for the office visit (99202), the x-ray of the lumbosacral spine 
(72100), the therapeutic exercises (97110) and the mechanical traction therapy (97012) provided by a 
chiropractor on August 22, 2023, to, August 25, 2023.  
 
You asked the Plan to pay for the office visit (99202), the x-ray of the lumbosacral spine (72100), the 
therapeutic exercises (97110) and the mechanical traction therapy (97012). You say that you have been going 
to the chiropractor and have been only paying a $20 copay. The Plan denied your request. The Plan says that 
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 (99202), the x-ray of the lumbosacral spine (72100), the 
therapeutic exercises (97110), and the mechanical traction therapy (97012) provided by a chiropractor on 
August 22, 2023, to, August 25, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for debridement (11042, 11045) provided on August 16, 2023, 
by an out-of-network (OON) provider.  
 You asked the Plan to pay for debridement. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the services were not referred by a network provider or rendered in a 
participating facility. The services were not urgent or emergent, nor were they approved in advance. 
 
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 debridement (11042, 11045) provided on August 
16, 2023, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the L3 kyphoplasty (22514). 
 
You asked the Plan to pre-approve the service. You say that this is needed to get the enrollee's pain under 
control. The Plan denied your request. The Plan says there is no documentation of an acute or subacute VCF at 
L3. 
 
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 medical records do not show that the fracture is less than 12 weeks old. 
 
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 L3 kyphoplasty (22514).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for diabetic supplies provided on June 23, 2023. 
 
You asked the Plan to pay for diabetic supplies. You say that this claim should be processed and paid. The Plan 
denied your request. The Plan says that the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does contain a valid physician order and proof of delivery. Review of the file does not reveal any 
reason that the required documentation is invalid. Therefore, we decided that the Plan has to pay for diabetic 
supplies provided on June 23, 2023.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intracept procedure (64628 and 64629). 
 
You asked the Plan to pre-approve the service. You say that the safety and efficacy of this procedure is robustly 
supported The Plan denied your request. The Plan says there are no Modic changes reported, and the records do 
not show an absence of non-vertebrogenic 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 the service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the magnetic resonance imaging (MRI) imaging does not document modic endplate changes 
which are required. 
 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 intracept procedure (64628 and 64629).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the admission to the LTACH is 
medically necessary. The Plan denied your request. The Plan says 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 the enrollee appears to be improving with current treatment and should only require 
short-term additional acute care services that can safely be provided at the current facility until more stable and 
appropriate for transfer to a lower level of care. The enrollee does not require LTACH services that are not 
already available at the current facility. Transfer to the LTACH is not medically necessary as it would not be 
clinically advantageous. Completion of treatment at the current facility is 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the fluoroscopic guidance for needle 
placement provided on August 16, 2023. 
 
You asked the Plan to waive the copayment for the fluoroscopic guidance for needle placement. You say that 
you want to appeal the amount being charged. 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 a $90 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $90 copayment for the fluoroscopic guidance for needle placement. This 
item/service falls within the outpatient diagnostic tests and therapeutic services and supplies 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 fluoroscopic guidance for needle placement provided on 
August 16, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the molecular pathology procedure (G0452) provided on 
May 12, 2023. 
 
You asked the Plan to pay for the molecular pathology procedure (G0452). The Plan denied your request. The 
Plan says the billed code is not supported. 
 
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 G0452 is molecular pathology procedure; physician 
interpretation and report. 
 
We asked our coder 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 molecular pathology procedure (G0452). Our reviewer says 
that procedure code G0452 is not supported by the medical record. Our reviewer found the record does not 
contain a physician interpretation and report of a molecular pathology procedure. Therefore, this code cannot 
be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of molecular pathology procedure (G0452) have not been met. Therefore, we 
decided that the Plan does not have to pay for the molecular pathology procedure (G0452) provided on May 12, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection (ESI).  
You asked the Plan to pre-approve injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are no imaging studies that show narrowing of the spine or how long conservative 
treatment has been tried. 
 
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 injection. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee has not completed four weeks of conservative therapy, such as physical therapy or 
chiropractic therapy. Therefore, the criteria has not been met and 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 injection have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an epidural steroid injection (ESI).
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 for transfer to an 
LTACH and meets the criteria for admission. The Plan denied your request. The Plan says the plan will 
continue to cover medically necessary acute and critical care at the current facility until the enrollee's condition 
is stable for transfer to an alternate level of care. 
 
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 the enrollee has diabetes, end-stage kidney disease on hemodialysis, diabetic 
neuropathy and gastroparesis, and hypertension and was admitted for necrotizing fasciitis. They underwent perineal/rectal/vaginal incision and drainage and other wound care procedures that resulted in a large wound. 
They also had an in-hospital cardiac arrest requiring intubation and resuscitation. They are no longer intubated, 
and their wound care needs are not sufficiently complex for LTACH admission. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377), harness for upgrade 
to expandable controller (E2313), and electronic connection between wheelchair controller and two or more 
power seating system motors (E2311). 
 
You asked the Plan to pre-approve an expandable controller, harness, and electronic connection. You say that 
the services are necessary. The Plan denied your request. The Plan says medical necessity has not been 
established. Therefore, coverage criteria have not been met. 
 
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 expandable controller, harness, and 
electronic connection. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the requested electrical accessories are not 
medically necessary as the enrollee does have use of the upper extremity and can operate and control the power 
options using the switches that are included in the basic wheelchair. There is not a medical need for the 
upgraded electronics. 
 
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 expandable controller, harness, and electronic connection have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377), harness for 
upgrade to expandable controller (E2313), and electronic connection between wheelchair controller and two or 
more power seating system motors (E2311).