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. The Plan denied your request. The Plan says this request does not 
meet the Plan's Part B step therapy criteria for the requested 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 Injectafer. Our reviewer says that the 
enrollee does not meet the criteria for coverage for Injectafer. Our physician reviewer found the health plan 
requires that other forms of iron be tried first. There is no evidence that the enrollee is allergic to or intolerant 
of these other forms of medication. Our reviewer found that there is no evidence that the enrollee has tried and 
not responded to these other forms of medication. There is no documentation as to why these other forms of 
medication would not be expected to be safe and effective for the enrollee. Our physician reviewer also found 
that the requested Injectafer is not shown to be currently medically necessary and reasonable. 
 
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: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Kit Sensor. 
 
You asked the Plan to pre-approve a Freestyle Kit Sensor. 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 must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a Freestyle Kit Sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Kit Sensor.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gelsyn-3 (J7328). 
 
You asked the Plan to pre-approve Gelsyn-3. You say that the enrollee has no cartilage in their knee. You say 
that the enrollee knows her options for surgery. You also say that the enrollee reports their pain to be at 100 
and can only walk around for a short time before icing it. The Plan denied your request. The Plan says the 
enrollee has not tried and failed any of the preferred drugs, Monovisc, Orthovisc, Synvisc or Synvisc One. 
 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 Gelsyn-3. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the provided documentation does not 
indicate that the enrollee has tried and failed any of the preferred drugs. The reviewer also found that the 
enrollee has a contraindication to or would have an adverse effect from the plan's preferred step one alternative. 
Therefore, the reviewer found that the step therapy criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gelsyn-3 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gelsyn-3 (J7328).
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve stereotactic body radiation therapy, treatment delivery, per fraction 
to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions (77373). 
 
You asked the Plan to pre-approve stereotactic body radiation therapy. You say that the enrollee has cancer and 
this procedure will help with treatment. The Plan denied your request. The Plan says that there is no 
documentation showing that this type of special radiation therapy (SBRT) is needed or effective for your 
cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 stereotactic body radiation therapy. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found that while the record describes oligoprogression, it does not appear that the 
enrollee had widespread metastases. For this enrollee, curative intent type treatment would be considered an 
appropriate standard of care in the absence of widespread metastases, particularly since systemic options are 
reportedly limited.  
 
While this is an uncommon clinical situation (limited metastases from a bladder cancer), and the ability to 
establish medical necessity based on robust data is challenging, SBRT for limited discrete metastases is an 
accepted standard of care as described above. The advantages of SBRT are to allow dose escalation while 
minimizing the volume of normal tissue exposed to high dose radiation. These principles coupled with the 
medically standard application of SBRT to oligometastatic sites would imply that standard medical necessity 
criteria would be met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of stereotactic body radiation therapy have been met. Therefore, we decided that 
the Plan has to pre-approve stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more 
lesions, including image guidance, entire course not to exceed 5 fractions (77373).  
 
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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc. 
 
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 the enrollee has left knee unilateral 
primary osteoarthritis. She has not tried and failed the Plan's required drugs, Orthovisc or Supartz FX. The 
records do not show that the required drugs would be contraindicated or less effective; therefore, Synvisc 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 Synvisc.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Promethazine. 
 
You asked the Plan to pre-approve Promethazine. 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. Medicare rules say that oral anti-emetic drugs that are used as full 
replacement for intravenous dosage forms of a cancer regimen are covered under specific circumstances. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Promethazine have not been met. Therefore, we decided that the Plan does not have to pre-approve 
Promethazine.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an external infusion pump and infusion supplies. 
 
You asked the Plan to pre-approve an external infusion pump and infusion supplies. 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 infusion pumps are covered 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 external infusion pump and infusion 
supplies. Our reviewer says that the services are not medically necessary. Our physician reviewer found the 
record indicates that the enrollee has multiple sclerosis and requires Ocrevus. Coverage for an external infusion 
pump and infusion supplies for the noted diagnosis and drug to be used is not available, by rule, under the 
coverage criteria. The elements of the coverage criteria are not satisfied. The requested service is not 
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 an external infusion pump and infusion supplies have not been met. Therefore, 
we decided that the Plan does not have to pre-approve an external infusion pump and infusion supplies.
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 the enrollee is currently hospitalized and cleared for 
discharge. The Plan denied your request. The Plan says based on Medicare guidelines the inpatient 
rehabilitation facility services you are requesting do not meet the requirements for approval. 
 
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 hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  The enrollee was admitted for non-surgical management of vertebral fractures, rib fractures, and a sternal 
fracture after a motor vehicle collision. Medical problems are stable. There are no complex nursing or 
rehabilitation needs. While the medical records support a need for physical 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 acute IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cemiplimab (J9119). 
 
You asked the Plan to pre-approve Cemiplimab. You say that the determination of the denial needs to be 
reviewed under the correct diagnosis of just lung cancer. The Plan denied your request. The Plan says the use 
of Cemiplimab for stage IIIB non-small cell lung cancer with programmed cell death ligand (PD-L1) 
expression Tumor Proportion Score of 30% with no estimated glomerular filtration rate (eGFR), anaplastic 
lymphoma kinase (ALK), or ROS1 aberrations is not FDA-approved or listed in the Medicare approved 
sources. 
 
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 Cemiplimab. Our reviewer says that the 
enrollee does not meet the criteria for coverage for Cemiplimab. Our physician reviewer found Cemiplimab is 
another chekpoint inhibiter. Our reviewer also found that as Opdivo was failed, Cemiplimab cannot be 
approved as same class of drug. 
 
  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Cemiplimab have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Cemiplimab (J9119).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion, subcutaneous cardiac rhythm monitor, 
including programming (33285). 
 
You asked the Plan to pre-approve the insertable loop recorder (ILR). You say that the enrollee needs this 
service. The Plan denied your request. The Plan says he requested service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that an insertable loop recorder (ILR) is used when 
syncope is thought to be cardiac-related but is too infrequent to be detected by either a HolterTM monitor or a 
traditional pre-symptom memory loop recorder (MLR). 
 
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 insertable loop recorder (ILR). Our 
reviewer says that the requested insertable loop recorder (ILR) is not medically necessary. Our physician 
reviewer found the provided documentation does not indicate that the enrollee has a history of unexplained 
syncope, cryptogenic stroke or any other apparent indication for an ILR. Therefore, the reviewer found that the 
requested ILR 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 the insertable loop recorder (ILR) have not been met. Therefore, we decided 
that the Plan does not have to pre-approve insertion, subcutaneous cardiac rhythm monitor, including 
programming (33285).
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested 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 you have a non-surgical pelvic fracture. Your rehabilitation requirements are to walk 
as tolerated as your fractures heal. You do not require intensive rehabilitation or frequent physiatry oversight. 
 
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 ventilator (E0466). 
 
You asked the Plan to pre-approve a ventilator. 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 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 ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the record indicates that the enrollee has 
chronic hypercarbic respiratory failure from chronic obstructive pulmonary disease. The record indicates that 
the enrollee was treated with bilevel positive airway pressure (BiPAP). 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 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 a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator (E0466).
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 needs special care at an IRF. The Plan 
denied your request. The Plan says based on Medicare guidelines, the requested IRF services do not meet the 
requirements for approval. 
 
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 complexity of the enrollees nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does 
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-
disciplinary rehabilitation program. 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient detoxification services. 
 
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. Medicare rules say that inpatient detoxification is covered 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee was admitted to the acute 
inpatient detoxification hospitalization on January 19, 2023, with uncomplicated alcohol and cocaine dependence. He was transferred to inpatient detoxification after stabilization in the mental health ward. It does 
not appear medically necessary and reasonable to have substance abuse care provided at the acute inpatient 
level of care, rather than a lower level of care, as he does not have dangerousness to self or others, perceptual 
disturbance including delusions, auditory or visual hallucinations and is not showing any withdrawals. The 
inpatient services are 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 inpatient detoxification services.