Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Stivarga 40MG tablet. 
 
You asked the Plan to pre-approve the medication. You say that this is an oral chemo and should be covered 
under Part B medical advanced colon cancer. The Plan denied your request. The Plan says that the medication 
is not covered. 
 
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 the medication. Our physician reviewer 
found the requested use of Stivarga 40MG tablet is FDA-approved for the enrollees diagnosis. The 
documentation supports that the requested drug is safe and effective and otherwise reasonable and necessary 
according to the NCCN compendium: Second-line therapy as a single agent (preferred): consider changing 
from previous regimen and using as adjuvant treatment for patients with poor response to preoperative 
chemotherapy in high-grade intramedullary + surface osteosarcoma for relapsed/refractory or metastatic 
disease. 
 
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 medication have been met. Therefore, we decided that the Plan has to pre-
approve Stivarga 40MG tablet.  
 
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: 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 LTACH care is not medically reasonable 
and necessary. The Plan denied your request. The Plan says rules for LTACH care have not been met. 
 
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 there is no documentation provided indicating medical necessity for admission to a 
LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not 
require services at the LTACH that are not available at the acute care hospital where he/she is currently 
receiving care. There are no services available at the LTACH that the enrollee requires that are not available at 
the health care setting being offered by the health plan. The requested LTACH services are not medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished 
safely and effectively only on an inpatient basis.  
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: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve the prolia (J0897). 
 
You asked the Plan to pre-approve the prolia. You say that the drug is medically necessary. The Plan denied 
your request. The Plan says that the drug is 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 the prolia. Our reviewer says that the 
service is medically necessary. Our physician reviewer found this drug is FDA approved for the member's 
diagnosis and the documentation supports that the requested drug is safe and effective and otherwise reasonable 
and necessary for this member. 
 
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 prolia have been met. Therefore, we decided that the Plan has to pre-
approve the prolia (J0897).  
 
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 bilateral L3-L5 medial branch block (MBB) injections 
for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there has not been three months of conservative management. 
 
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 there is significant radiographic evidence (8/30/2021 lumbar MRI scan) showing 
significant non-facet lower back pain generators including: L4-5 severe central canal stenosis with degenerative 
mild spondylolisthesis-grade 1 and at the right of L5-S1 neuro compression by a large right synovial cyst with 
severe impingement at the right L5-S1 lateral recess. Additionally, she has not received and failed at least three 
months of recent conservative care for the recurrent, residual axial lower back pain. 
 
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 bilateral L3-L5 medial branch block (MBB) injections for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that you are not stable when walking. The Plan 
denied your request. The Plan says you do not require daily skilled therapy services on an inpatient basis. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF services. Our physician reviewer 
found that you were admitted to the hospital after a mechanical fall resulted in low back and hip pain. You have 
stabilized medically and are ready for discharge from the hospital. You do not require skilled nursing or 
therapy services on a daily basis. You do not have any acute exacerbations of chronic medical problems. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve enteral formula for the enrollee. 
 
You asked the Plan to pre-approve the formula. You say that this is medically necessary. The Plan denied your 
request. The Plan says this benefit is not included for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 
 
The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be 
appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan 
does not have to pre-approve enteral formula for the enrollee.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lupron Depot (3-MONTH) Kit 22.5MG (CPT code 
J9217 x6). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says they do not have a record from the enrollee's prescriber that shows the enrollee has 
tried the preferred drug Eligard and it has not worked, or that they have medical reasons that prevent the 
enrollee from using it.  
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 medication. Our physician reviewer 
found 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 the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Lupron Depot (3-MONTH) Kit 22.5MG (CPT code J9217 x6).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve daratumumab (J9144), gemcitabine hydrochloride 
(J9201) and oxaliplatin (J9263). 
 
You asked the Plan to pre-approve daratumumab (J9144), gemcitabine hydrochloride (J9201) and oxaliplatin 
(J9263). You say that the patient has highly aggressive, rapidly growing lymphoma and needs urgent systemic 
chemotherapy and targeted therapy. The Plan denied your request. The Plan says the requested regimen has no 
support in the compendia utilized by Medicare nor is there any support in the literature approved by Medicare. 
 
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 daratumumab (J9144), gemcitabine 
hydrochloride (J9201) and oxaliplatin (J9263). Our reviewer says that the elements of the coverage criteria are 
not satisfied, and the requested service cannot be recommended. Our physician reviewer found that the FDA 
has not stated that the requested drug regimen is 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 regimen in the 
enrollee's clinical situation and no literature from Medicare approved cancer journals were submitted for 
review. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of daratumumab (J9144), gemcitabine hydrochloride (J9201) and oxaliplatin 
(J9263) have not been met. Therefore, we decided that the Plan does not have to pre-approve daratumumab 
(J9144), gemcitabine hydrochloride (J9201) and oxaliplatin (J9263).
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 you have been in the hospital for a week and have 
not walked all week. You say that you need specialized physical therapy equipment to learn to walk again and 
the decision should be revisited. The Plan denied your request. The Plan says an acute inpatient rehabilitation 
facility stay is not medically necessary and is not approved at this time. 
 
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 documentation does not support that you require treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of multi-component, inflatable penile 
prosthesis, including placement of pump, cylinders, and reservoir (CPT code 54405). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says there is no documentation that you have tried and failed a trial of intraurethral 
alprostadil and a vacuum erection device (VED). 
 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found insertion of multi-component, inflatable penile prosthesis, including placement of pump, 
cylinders, and reservoir (CP) code 54405) is not medically reasonable and necessary. The records do not 
indicate failure of VED, urethral suppositories, or penile injections. 
 
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 service have not been met.  Therefore, we decided that the Plan does not have to pre-approve insertion of multi-component, inflatable 
penile prosthesis, including placement of pump, cylinders, and reservoir (CPT code 54405).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an outpatient office visit, scanning computerized ophthalmic 
diagnostic imaging and a diagnostic eye procedure provided on November 19, 2021. 
 
You asked the Plan to pay for an outpatient office visit, scanning computerized ophthalmic diagnostic imaging 
and a diagnostic eye procedure. The Plan denied your request. The Plan says prior authorization was not 
obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for an outpatient office visit, scanning computerized ophthalmic 
diagnostic imaging and a diagnostic eye procedure provided on November 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for therapeutic continuous glucose 
monitor (CGM) (K0553) provided April 12, 2021. 
 
You asked the Plan to pay for the therapeutic CGM supply allowance. You say that please review the attached 
medical records. The Plan denied your request. The Plan says evidence of misrepresented services 
 
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 supply allowance for therapeutic 
continuous glucose monitor (CGM) (K0553) provided April 12, 2021. have been met. The Plan was unable to 
discover any evidence of an established relationship between the enrollee and the ordering physician. The Plan 
made multiple attempts to the provider to confirm treatment history and validate the written order without 
success. Therefore, we decided that the Plan does not have to pay for the supply allowance for therapeutic 
continuous glucose monitor (CGM) (K0553) provided April 12, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF services. 
 
You asked the Plan to pre-approve SNF services. You say that you are unable to take care of yourself and get 
around. The Plan denied your request. The Plan says your request does not show you have skilled nursing or 
therapy needs that need to be provided on a daily basis as an inpatient only status. 
  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that based on the medical records 
provided there is no documentation that the enrollee requires services on an inpatient basis, only in a skilled 
nursing facility setting. Services in the home with home health care or in a long-term care facility on a part time 
basis are appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services. have not been met. Therefore, we decided that the Plan does not 
have to pre-approve SNF services.
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 and the enrollee feel the enrollee is most 
appropriate for acute inpatient rehabilitation to complete his multidisciplinary therapy program. The Plan 
denied your request. The Plan says the IRF 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 patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer 
found that the patient does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. While the patient has a need for physical 
and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. Our 
physician reviewer also found that there is not a reasonable expectation that this patient 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on June 21, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 87798 is not covered. 
 
The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of X are 
statutorily excluded.  
 
We looked at the file and Medicare rules. Billed procedure code 87798 (infectious agent detection by nucleic 
acid (DNA or RNA), not otherwise specified; amplified probe technique, each organism) has a status indicator 
of X and is statutorily excluded from Medicare payment. Therefore, we decided that the Plan does not have to 
pay for the laboratory services rendered on June 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous process 
stabilization/distraction 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 experimental and investigational procedures are not covered by Medicare. 
 
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 services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that these interspinous process devices are experimental. More research is 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 insertion of interlaminar/interspinous process stabilization/distraction device for the enrollee.