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

 
We decided that the Plan does not have to pre-approve Octagam. 
  You asked the Plan to pre-approve Octagam. The Plan denied your request. The Plan says there was no 
contradiction or intolerance to the preferred drug. 
 
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 Octagam. Our reviewer says that the 
enrollee has not tried and failed the required drug. Our physician reviewer found there is no documentation 
provided indicating that the required drug would likely be less effective 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 Octagam have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Octagam.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection (64479).  
You asked the Plan to pre-approve an epidural steroid injection. You say that the requested services are a 
medical necessity for the enrollee. The Plan denied your request. The Plan says the requested services are 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 an epidural steroid injection. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found that there is no documentation of Physical Therapy, Chiropractic or other 
conservative physical medicine therapies, nor a reason why the enrollee cannot tolerate such therapies. 
 
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 (64479).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the IMRT (77386 and 77014). 
 
You asked the Plan to pre-approve the IMRT. You say that the services are medically necessary. The Plan 
denied your request. The Plan says there is no good comparison evidence in the records that this type of special 
radiation therapy is needed or effective for the enrollee's cancer. 
 
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 IMRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the treatment does not seem to be a standard of care approach and plausible rationale for the 
need of 30 fractions of IMRT versus more standard approaches was not provided. 
 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 IMRT have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the IMRT (77386 and 77014).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient services provided from September 22, 2022, to 
October 6, 2022. 
 
You asked the Plan to pay for the inpatient services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the inpatient care was not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the inpatient services have been met. 
The file is missing medical records. Therefore, we decided that the Plan does not have to pay for inpatient 
services provided from September 22, 2022, to October 6, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device insertion. 
 
You asked the Plan to pre-approve the Vertiflex device insertion. You say that the enrollee has had several 
years of conservative treatment without relief, and they have an approved indication for this device. You say 
that this treatment is medically necessary and appropriate for this stage of the disease progression. The Plan 
denied your request. The Plan says there are not enough studies on Vertiflex Superion to show it is safe and 
effective to treat back 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 Vertiflex device insertion. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show 
safety and efficacy. 
 
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 Vertiflex device insertion have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Vertiflex device insertion.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that without IRF service the enrollee's health and ability 
to regain maximum function is seriously jeopardized. The Plan denied your request. The Plan says the request 
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 enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve therapeutic radiology simulation-aided field setting; 
complex (77290), high dose rate electronic brachytherapy, skin surface application, per fraction, includes basic 
dosimetry, when performed (0394T), and therapeutic radiology simulation-aided field setting; simple (77280). 
 
You asked the Plan to pre-approve the services. You say that the enrollee's medical diagnosis may benefit from 
this procedure. The Plan denied your request. The Plan says there are insufficient long-term efficacy and safety 
data to support the routine use of electronic surface brachytherapy. The Plan states the enrollee's records do not 
show that the enrollee has undergone clinic staging, consideration for resection of the remaining lesion, or 
consideration for alternate treatment options. 
 
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 services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there are no compelling reasons offered for why stereotactic radiotherapy (SRT) would be 
needed over more standard approaches of radiation delivery. Our physician reviewers decision in this case is 
unfavorable due to lack of demonstration of need for SRT versus traditional external beam radiation. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve therapeutic radiology simulation-aided field setting; complex (77290), high dose rate 
electronic brachytherapy, skin surface application, per fraction, includes basic dosimetry, when performed 
(0394T), and therapeutic radiology simulation-aided field setting; simple (77280).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF services will give the enrollee the opportunity to 
get better with rehabilitation 7 days a week versus the 1 day a week offered at a skilled nursing facility (SNF). 
The Plan denied your request. The Plan says 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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. While the enrollee may have a need for physical therapy and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. There is not a reasonable expectation that the enrollee will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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 an IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda and bevacizumab. 
 
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 services 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found that the enrollee has a diagnosis of 
metastatic recurrent serous ovarian cancer that is BRCA negative and PDL1 positive. The Food and Drug 
Administration (FDA) has not stated that the drugs are indicated for the enrollee's condition. The Medicare-approved cancer drug compendia do not contain a supportive citation for the use of the requested drug in the 
enrollee's specific clinical situation. No literature from Medicare approved cancer journals were submitted for 
review. The services are therefore 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 Keytruda and bevacizumab.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the ventilator is medically necessary. The 
Plan denied your request. The Plan says the ventilator is not medically necessary. 
 
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 the home ventilator. Our physician 
reviewer found the record indicates that the enrollee has chronic hypoxic and hypercapnic respiratory failure from chronic obstructive pulmonary disease. The provided primary source documentation does not contain 
sufficient detailed information in the medical record to justify the treatment selected. The enrollee could be 
treated with a bilevel positive airway pressure (BiPAP) machine with average volume-assured pressure support 
(AVAPS) capability. The Plan has indicated coverage for such a device is available upon request. 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 the home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the ventilator is medically necessary. The 
Plan denied your request. The Plan says the ventilator is not medically necessary. 
 
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 the home ventilator. Our physician 
reviewer found the provided records document that the home ventilator is being requested for use in average volume assured pressure support (AVAPS) mode with auto-EPAP (AE) which could be provided by a bilevel 
positive airway pressure (BiPAP) device with AVAPS and a back-up rate. Provided records do not document 
trial and failure of a BiPAP device with AVAPS and a back-up rate. As stated in the LCD (L33800): "Claims 
for ventilators used to provide CPAP or bi-level CPAP therapy for conditions described in this RAD policy will 
be denied as 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 the home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for procedure code A4557 rendered on September 15, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that this procedure has been billed and allowed the maximum number of times allowed by the 
payment policy. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The plan has not specified what payment policy is being used for their denial. 
The plan has not forwarded a comprehensive enough denial for this case. Therefore, we decided that the Plan 
has to pay for procedure code A4557 rendered on September 15, 2022.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pre-fabricated knee orthosis (L1852). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not show recent injury or surgery, or that the enrollee has instability. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee is ambulatory, but the documentation does not reveal evidence of objective joint laxity 
or instability on a physical examination. There is no evidence of a recent injury or surgery to the left knee.  
 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a pre-fabricated knee orthosis (L1852).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient care provided from August 23, 2022, to  
August 24, 2022. 
 
You asked the Plan to pay for the inpatient care. You say that the services were medically necessary. The Plan 
denied your request. The Plan says this service was not authorized. 
 
The Plan contract says that the Plan covers inpatient hospital care. Prior authorization may be required 
and is the responsibility of the enrollee's provider. 
 
We looked at the file and Plans rules. The file shows that the inpatient care was not authorized. Based on this 
information, we decided that the Plans rules for coverage of the inpatient care have not been met. Therefore, 
we decided that the Plan does not have to pay for inpatient care provided from August 23, 2022, to  
August 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the seat lift mechanism, electric, any type 
(E0627). 
 
You asked the Plan to reimburse you for the seat lift mechanism. You say that you are dissatisfied with the 
denial of a reimbursement for a seat lift mechanism. You feel the seat lift mechanism should be covered as you 
cannot lay flat or get out of bed by yourself. The Plan denied your request. The Plan says the available medical 
records do not support necessity of the device as defined by Medicare criteria. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section 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 reimburse you for the seat lift mechanism. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the provided records in this case document rheumatoid arthritis and 
thoracic and lumbar compression fractures, but the records do not specifically document severe arthritis of the 
hip or a neuromuscular disease. The records do not document a plan of care indicating need for the seat lift 
mechanism or need for the seat lift mechanism which would result in improvement in the enrollees condition 
or arrest or retard deterioration in the patient's condition. The provided records in this case do not document the 
enrollee is completely incapable of standing from a chair in the home. The records in this case document the 
enrollee "walks with a normal gait." 
 
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 seat lift mechanism have not been met. Therefore, we decided that the Plan 
does not have to reimburse you for the seat lift mechanism, electric, any type (E0627).