Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve the inpatient psychiatric admission requested on August 22, 2020. 
 
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that this is necessary. The 
Plan denied your request. The Plan says that the enrollee could have been managed in the outpatient setting. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric hospital services. 
Our reviewer says that the requested inpatient level of care is considered medically reasonable and necessary in 
this case. Our physician reviewer found this 49-year-old male was admitted to the acute inpatient psychiatric 
hospitalization on August 22, 2020 with Schizoaffective Disorder Bipolar Type, Antisocial Personality 
Disorder and Factitious Disorder. Based upon review the records provided it was expected this enrollee would 
improve in a reasonable period of time as he did have dangerousness to self but not others, auditory or visual 
hallucinations, delusions. It did appear medically necessary and reasonable to have psychiatric care provided at 
the acute inpatient level of care rather than a lower level of care as he did have dangerousness to self but not 
others, perceptual disturbance including delusions, auditory or visual hallucinations. The health plan?s denial of 
inpatient psychiatric services appears inappropriate. This enrollee did appear to require inpatient mental health 
treatment as he was a danger to himself but not others. It did appear that active treatment was taking place. It 
did appear that the services were reasonably expected to improve the patient?s condition or for the purpose of 
diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric hospital services have been met. Therefore, we decided 
that the Plan has to pre-approve the inpatient psychiatric admission requested on August 22, 2020.  
 
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 Epoetin Alfa (Epogen). 
 
You asked the Plan to pre-approve Epogen. The Plan denied your request. The Plan says the enrollee does not 
meet coverage 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 the Epogen. Our reviewer says that 
Epogen is not medically reasonable and necessary for the enrollee. Our physician reviewer found the enrollee's 
documented medical conditions are not medically accepted indications for the use of Epoetin Alfa. There are 
no citations in the Medicare approved compendia that support the use of the requested drug for treatment of the 
enrollee's conditions.  Therefore, the requested drug is not eligible for coverage under Medicare Part B. 
 
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 Epogen have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Epoetin Alfa (Epogen).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Mild procedure (0275T). 
 
You asked the Plan to pre-approve the Mild procedure (0275T). You say that the Mild procedure is medically 
necessary. The Plan denied your request. The Plan says the enrollee is not enrolled in a research study. 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
We looked at the file and Medicare rules. Medicare rules say that percutaneous image-guided lumbar 
decompression or commercially known as the mild procedure will be covered when provided in an approved 
clinical study. The file does not show that the enrollee is enrolled in an approved clinical study. Therefore, we 
decided that the Plan does not have to pre-approve the Mild procedure (0275T).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a facet joint injection.
You asked the Plan to pre-approve facet joint injection. You say that you have had a pain implant, steroid injection, and facet injections with no success, but if this is not approved you will need to have major surgery. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because previous injections only provided 50% and 60% pain relief, not 100% relief.
The Plan follows Medicare rules. Medicare rules say that facet joint injections are only covered when certain clinical criteria are met. Facet joint injections are not considered medically reasonable and necessary when the enrollee did not experience temporary or prolonged abolition of pain after previous injections.
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 facet joint injection. Our reviewer says that you do not meet the Medicare criteria for the requested facet joint injection. Our physician reviewer found the medical records show that the procedure you received on June 10, 2020 provided pain relief of 50%, and
the procedure on July 13, 2020 provided pain relief of 60%. The rules state that you should obtain 100% relief from these procedures to cover further procedures. Therefore, the requested facet joint injection 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 facet joint injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a facet joint injection.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Prolia (denosumab) for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the information provided by the doctor does not meet the Medicare guidelines. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the drug. Our reviewer says that the 
requested drug is medically reasonable and necessary. Our physician reviewer found the enrollee has tried and 
failed oral or self-administered drugs for osteoporosis. The enrollee has a normal calcium level and a Vitamin 
D level (25-hydroxy vitamin D) level of 25 ng/ml. Per the clinical documents, the enrollee is supplementing 
with calcium and Vitamin D daily. The provider has documented that the enrollee will not use in combination 
with antiresorptive or anabolic agents. Per DrugDex, a Medicare approved compendium, hypocalcemia is 
contraindicated and must be corrected before initiating therapy. The review indicates that the documentation 
supports that the Prolia is medically reasonable and necessary for the enrollee. The enrollee has a normal serum 
calcium and the vitamin D level is more than 20 ng/ml. The documentation supports that the Prolia is safe and 
effective 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 the drug have been met. Therefore, we decided that the Plan has to pre-approve 
Prolia (denosumab) for the enrollee.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Entyvio (J3380). 
 
You asked the Plan to pre-approve Entyvio. You say that the medication is necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Entyvio. Our reviewer says that the 
medication is not medically necessary. Our physician reviewer found the documentation does not support the 
Entyvio is medically reasonable or necessary for this enrollee. The documentation does not support that 
Entyvio is safe and effective 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 Entyvio have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Entyvio (J3380).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xolair.
You asked the Plan to pre-approve Xolair. You say that the enrollee's symptoms have greatly improved with no negative effects or adverse reactions. The Plan denied your request. The Plan says the drug is not covered under the medical benefit sine the physician will not be furnishing the medication.
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Xolair.
Benefits for Xolair 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex interspinous and/or interlaminar device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says medical studies have not proven that this device is helpful for treatment of the health problem.
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 device. Our reviewer says that the requested device is not considered medically reasonable and necessary in this case. Our physician reviewer found the device is experimental for use in spine surgery. More research is needed to show safety and efficacy. There is no spinal instability in this case. It is not needed. 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex interspinous and/or interlaminar device for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vitamin B12 injections. 
 
You asked the Plan to pre-approve the Vitamin B12. You say that you do not absorb B-12 properly, and must 
be given by injection. You also say that you would like to self-administer this drug during the pandemic. The 
Plan denied your request. The Plan says self-administration of this drug is not covered under Medicare Part B. 
 
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. Vitamin B12 is covered if administered by a physician. Therefore, we decided that the Plan 
does not have to pre-approve Vitamin B12 injections.  
 
Benefits for the Vitamin B12 may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says based on the Medicare guidelines and the information about the enrollee's condition, they don't meet the requirements.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the review has determined that the documentation does not support that Keytruda is medically reasonable and necessary for the enrollee. The documentation does not support that Keytruda is safe and effective for the enrollee. In this case, the enrollee is dMMR/MSI stable. The use of Keytruda in rectal cancer is only indicated with dMMR-MSI-High; PD-L1 status for this cancer type is not a criterion for use of Keytruda. 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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda for the enrollee.
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 you are a very high risk for fall and could get another 
stroke. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 your condition is stable with no evidence of need for supervision by an acute 
rehabilitation physician or acute rehabilitation nursing care. While you may benefit from further physical 
therapy and occupational therapy, you do not require an intensive therapy program. At the current level of 
function, you do not require 15 hours per week of therapy services in an IRF. Your rehabilitation needs can be 
met in a lower intensity setting such as in-home therapy. 
 
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Horizant tablets.
You asked the Plan to pre-approve the Horizant tablets. You say that the enrollee has been on this medication
for a while, and has tolerated it well. You also say that to switch to an alternate drug would not be in the
enrollee's best interest. The Plan denied your request. The Plan says this drug is not covered for the enrollee's
condition by Medicare Part B.
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B,
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill.
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be
brought to the office for administration. Since the medication does not represent an expense to the physician
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that
the Plan does not have to pre-approve Horizant tablets.
Benefits for the Horizant tablets may be available under Medicare Part D. Contact the Plan that administers
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Gel-One injections (J7326).
You asked the Plan to pre-approve Gel-One injections. You say that the injections are medically necessary. The Plan denied your request. The Plan says that coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Gel-One injections. Our reviewer says that the Gel-One injections are medically necessary. Our physician reviewer found the enrollee has completed conservative therapy, tried and failed a home exercise program, and steroid injections without functional improvement. Radiologic findings support the clinical diagnosis of osteoarthritis. Intra-articular injections with hyaluronic acid (Gel-One) are medically 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 Gel-One injections have been met. Therefore, we decided that the Plan has to pre-approve Gel-One injections (J7326).
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 Darbepoetin Alfa (Aranesp).
You asked the Plan to pre-approve Aranesp. You say that this is not a medication which you normally take. The Plan denied your request. The Plan says the enrollee does not have a history of failure, contraindication, or intolerance to the formulary alternative, Retacrit. The Plan also says that this is not a continuation of therapy in the past 365 days.
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 Aranesp. Our reviewer says that Aranesp is not medically necessary. Our physician reviewer found the submitted medical information does not indicate the enrollee has been treated with Retacrit. Our reviewer also found that the Plan's required drug would not 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 Aranesp have not been met. Therefore, we decided that the Plan does not have to pre-approve Darbepoetin Alfa (Aranesp).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (J0897). 
 
You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says the information 
submitted does not meet the Plan's medical necessity guidelines for coverage. 
 
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 Prolia 
does not meet the Plan's coverage criteria. Our physician reviewer found the enrollee has not tried and failed 
the required drug, Zoledronic Acid. Our reviewer also found that there is no documentation provided indicating 
that the Plan?s required drug 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia (J0897).