Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve iron dextran injections (J1750).
You asked the Plan to pre-approve iron dextran. You say that iron dextran is medically necessary for this enrollee. The Plan denied your request. The Plan says the criteria for medical necessity for iron dextran are not met. Specifically, the enrollee's hemoglobin level is higher than it should be to qualify for the iron infusions.
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 rWe decided that the Plan does not have to pre-approve iron dextran injections (J1750).
You asked the Plan to pre-approve iron dextran. You say that iron dextran is medically necessary for this enrollee. The Plan denied your request. The Plan says the criteria for medical necessity for iron dextran are not met. Specifically, the enrollee's hemoglobin level is higher than it should be to qualify for the iron infusions.
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 iron dextran. Our reviewer says that the criteria for coverage of iron dextran are not met. Our physician reviewer found in this case, documentation shows that the enrollee's hemoglobin level on October 20, 2021, was 13.8. The guidelines state it must be less than 12 to qualify for the iron infusions. The review has determined that the documentation does not support that the Iron dextran is medically reasonable and necessary for the enrollee. The documentation does not support that the Iron dextran 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 iron dextran have not been met. Therefore, we decided that the Plan does not have to pre-approve iron dextran injections (J1750).easonable 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 iron dextran. Our reviewer says that the criteria for coverage of iron dextran are not met. Our physician reviewer found in this case, documentation shows that the enrollee's hemoglobin level on October 20, 2021, was 13.8. The guidelines state it must be less than 12 to qualify for the iron infusions. The review has determined that the documentation does not support that the Iron dextran is medically reasonable and necessary for the enrollee. The documentation does not support that the Iron dextran 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 iron dextran have not been met. Therefore, we decided that the Plan does not have to pre-approve iron dextran injections (J1750).