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

 
We decided that the Plan does not have to pre-approve Injectafer. 
 
You asked the Plan to pre-approve Injectafer. You say that the requested Injectafer is medically necessary. The 
Plan denied your request. The Plan says the enrollee must try and fail Infed and Venofer first. 
 
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 Injectafer. Our reviewer says that the 
Plan's step therapy criteria have not been met. Our physician reviewer found the Plan requires a trial of drug 
Infed and/or Venofer 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 Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tiering exception for Sirolimus. 
 
You asked the Plan to pre-approve a tiering exception for Sirolimus. You say that the exception is needed. The 
Plan denied your request. The Plan says the drug does not qualify for tier exceptions. 
 
The Plan must follow Medicare rules. Medicare rules say that tiered cost-sharing means a process of grouping 
Part D drugs into different cost sharing levels within a Part D sponsor's formulary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a tiering exception for Sirolimus have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a tiering exception for Sirolimus.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) to the sacroiliac (SI) 
joint. 
 
You asked the Plan to pre-approve RFA to the SI joint. 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 RFA to the SI joint. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are limited large-scale, long-term references showing the safety and efficacy of 
the requested surgery in this clinical setting. There is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested 
RFA to the SI joint, in this case, 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 RFA to the SI joint have not been met. Therefore, we decided that the Plan does 
not have to pre-approve radiofrequency ablation (RFA) to the sacroiliac (SI) joint.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone and/or joint imaging; whole body (78306). 
 
You asked the Plan to pre-approve a whole-body bone scan. You say that the enrollee has had overactive 
bladder and urge incontinence. She has post void residual today of 0 mls. She was placed on oxybutynin XL 
and had dry mouth and constipation along with back pain. She was seen in the emergency room in February of 
2023 with left-sided abdominal pain. She is status post nephrectomy and non-contrast CT scan failed to show 
any evidence of mass or hydronephrosis or stones. The Plan denied your request. The Plan says the whole-body 
bone scan does not meet our guidelines for coverage. There is no documented history of malignancy (cancer), 
bone pain, rising tumor markers (test to show presence of cancer) or suspected bony metastases (secondary 
malignant growth) documented. 
 
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 whole-body bone scan. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has left flank pain, microscopic hematuria, urinary tract infection, urge 
incontinence and overactive bladder. She also had a right nephrectomy for oncocytoma in the past. She had a 
noncontrast abdominal/pelvic CT scan on February 13, 2023, which was unremarkable. She had an abdominal 
ultrasound that showed benign left renal cysts. Bone and/or joint imaging; whole body is not medically 
reasonable and necessary in this case. The records do not show that the enrollee has a history of malignancy, 
bone pain, rising tumor markers or suspected bony metastases. 
 
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 whole-body bone scan have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a bone and/or joint imaging; whole body (78306).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says that the admission to an IRF is not medically necessary. 
 
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 that the enrollee is functioning at a home care level and does not require intensive 
rehabilitation. 
 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 IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a left shoulder magnetic resonance imaging (MRI), 
without and with contrast (73223). 
 
You asked the Plan to pre-approve a left shoulder MRI, without and with contrast. You say that the enrollee 
needs an MRI. The Plan denied your request. The Plan says for typical shoulder pain, the requested test is not 
reasonable and carries some small amount of risk. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 a left shoulder MRI, without and with 
contrast. Our reviewer says that the service is not medically necessary. Our physician reviewer found that in 
this case there were no abnormalities reported on physical exam and no x-ray obtained. In addition, there is no 
indication for intravenous (IV) contrast. The review has determined that the requested MRI with and without 
contrast is not 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 a left shoulder MRI, without and with contrast have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a left shoulder magnetic resonance imaging (MRI), 
without and with contrast (73223).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found that the enrollee has a diagnosis of 
unspecified iron deficiency anemia. She has not tried and failed the Plan's required drugs, Infed and Venofer. 
The records do not show that the required drugs would be contraindicated or less effective; therefore, Feraheme 
is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Feraheme.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Imjudo plus Imfinzi combination. 
 
You asked the Plan to pre-approve Imjudo plus Imfinzi combination. You say that the requested Imjudo plus 
Imfinzi combination is medically necessary. The Plan denied your request. The Plan says the enrollee must try 
and fail atezolizumab plus bevacizumab combination first. 
 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 Imjudo plus Imfinzi combination. Our 
reviewer says that the Plan's step therapy criteria have not been met. Our physician reviewer found the record 
indicates that the enrollee has hepatocellular carcinoma. The requested medication is a new start. The provided 
records do not indicate that the enrollee has tried and failed the plan's preferred step one alternative. The record 
does not indicate that the enrollee has a credible contraindication to or would have an adverse effect from the 
plan's preferred step one alternative. The elements of the coverage criteria are not satisfied. 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 Imjudo plus Imfinzi combination have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Imjudo plus Imfinzi combination.
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 the enrollee will benefit from an intense therapy 
program of 15 hours to enable to return to prior level of independence. The Plan denied your request. The Plan 
says there are no active comorbidities documented that would require inpatient hospitalization during 
rehabilitation, the enrollee's needs can be met at a lower level of care. 
 
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 the enrollees nursing, medical and rehabilitation needs do not 
require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the requested home ventilator is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for a home 
ventilator. 
 
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. 
 
 
 
 
 
 
 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. Our reviewer says 
that the enrollee does not meet criteria for a home ventilator. Our physician reviewer found this enrollee has 
chronic obstructive pulmonary disease (COPD), and two recent hospitalizations for exacerbations. An arterial 
blood gas (ABG) test during one of those hospitalizations is consistent with acute on chronic hypercarbic 
respiratory failure. There is no ABG done while stable to confirm chronic CO2 retention. If the enrollee does 
have chronic CO2 retention, they may benefit from bilevel positive airway pressure (BiPAP) with average 
volume-assured pressure support (AVAPS) during sleep. This has not been shown to fail as an outpatient. 
Medicare does not cover a home ventilator when used at settings that can be provided with BiPAP. 
 
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 have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that the requested epidural steroid 
injection is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet 
criteria for the requested epidural steroid injection. 
 
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 epidural steroid injection. Our 
reviewer says that the enrollee does not meet criteria for the requested epidural steroid injection. Our physician 
reviewer found the records show that the enrollee does not have a history, physical examination, or imaging 
findings to indicate that thoracic radiculopathy is the source of the pain. She was noted to have mid back pain, 
but radiation of that pain in a dermatomal pattern was not documented in the history or physical examination, 
and thoracic imaging was not provided. The review has determined that the enrollee does not meet the LCD 
criteria for the requested thoracic epidural steroid injection. 
 
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 epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection.
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 enrollee needs to be transferred to 
LTACH requiring a multi-disciplinary approach for an extended period. The Plan denied your request. The 
Plan says a discharge to a lower level of care would not be appropriate, the enrollee has ongoing acute care 
needs, when medically stable and no longer requiring an acute level of care, the ongoing needs for skilled 
therapy, respiratory therapy, and skilled nursing may be completed in a lower level of care, an inpatient 
rehabilitation facility or even a skilled nursing facility. 
 
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 still be improving and should only require short-term 
additional acute care services that can safely be provided at the current facility until more stable for transfer and 
does not require services at the LTACH that are not already available at the current facility. 
 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that admission to IRF is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for 
admission to an IRF. 
 
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 there are no complex nursing or rehabilitation needs. While the enrollee needs a need 
for physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. 
 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued tertiary level of care. 
 
You asked the Plan to pre-approve continued tertiary level of care. You say that the continued tertiary level of 
care is medically necessary. The Plan denied your request. The Plan says the continued tertiary level of care 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 continued tertiary level of care. Our 
reviewer says that the continued tertiary level of care is not medically necessary. Our physician reviewer found 
the Plan's denial is medically justified on the basis that it is offering adequate care to meet the enrollee's 
medical needs through referral to a non-tertiary level provider. This enrollee can be cared for by any 
hematologist/oncologist and does not require tertiary care. A plan is in place for treatment with procedure 
going forward and can be carried out outside of a tertiary care center. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued tertiary level of care have not been met. Therefore, we decided that 
the Plan does not have to pre-approve continued tertiary level of care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that epidural steroid injection (ESI) will be considered 
medically reasonable and necessary 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 an epidural steroid injection. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found there is no imaging 
submitted with the documentation and therefore, the request does not meet the LCD criteria. 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 an epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection.