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

 
We decided that the Plan does not have to pre-approve Botox. 
 
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 bladder hyperactivity 
and has tried and failed one anticholinergic medication. She has not tried and failed the Plan's requirement of 
behavioral therapy and two anticholinergic medications. The records do not show that the required drugs would 
be contraindicated or less effective; therefore, Botox 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 Botox.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve enteral nutrition (Enterade Advanced Oncology 
Formula). 
 
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 enteral formula 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 records do not document that you 
require feedings from a feeding tube to provide sufficient nutrients to maintain weight and strength. You do not 
have permanent full or partial non-function or disease of the structures that permit food to reach the small 
bowel or a disease that impairs digestion and/or absorption of an oral diet. The criteria for coverage are not met 
and the 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 enteral nutrition (Enterade Advanced Oncology Formula).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transthoracic echocardiogram (TTE) (93306). 
 
You asked the Plan to pre-approve a TTE. You say that the service is medically necessary. The Plan denied 
your request. The Plan says the requested service 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 a TTE. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found in the absence of any symptoms according to the submitted records, clinical guidelines do not 
support carrying out a TTE in this setting. In summary, there is no supportive evidence for the medical 
necessity of a TTE in this this enrollees clinical management. 
 
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 TTE have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a transthoracic echocardiogram (TTE) (93306).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp. 
 
You asked the Plan to pre-approve Aranesp. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
 
 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 Aranesp. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has anemia in chronic kidney disease. The documentation does not support that the enrollee 
has tried and failed Retacrit or Procrit. The documentation does not support that Retacrit or Procrit would likely 
be less effective and/or likely have adverse effects for the enrollee. Therefore, the enrollee does not meet 
criteria for the requested 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 Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve spinal fusion with allograft. 
 
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 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the use of an allograft is considered 
experimental in cases of spinal fusion. The services are therefore not reasonable or medically necessary 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve spinal fusion with allograft.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous passive motion exercise device (E0936). 
 
You asked the Plan to pre-approve a continuous passive motion exercise device. You say that this item is 
medically necessary. The Plan denied your request. The Plan says this device is not being used after a total 
knee replacement. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that a continuous passive motion exercise device is being requested for use in a SNF or hospital. 
Therefore, we decided that the Plan does not have to pre-approve a continuous passive motion exercise device 
(E0936).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable/inserted device described by code 
C1889. 
 
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 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee underwent a colonoscopy. 
The records are insufficient to establish the medical necessity of the requested implantable device. The services 
are not reasonable or medically necessary for the enrollee based on the submitted documentation. 
 
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 an implantable/inserted device described by code C1889.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient services billed with DRG 070 on June 27, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the billed DRG is 
not supported. 
 
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 argues that the billed DRG is not supported as the records do not 
support G93.9 as the principal diagnosis. However, the documentation submitted by the Plan does not contain 
medical records for the inpatient admission. Without medical records, the Plan's denial cannot be substantiated. 
Therefore, we decided that the Plan has to pay for the inpatient services billed with DRG 070 on June 27, 2021.  
 
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: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Udenyca (Q5111). 
 
You asked the Plan to pre-approve Udenyca. You say that the enrollee has chemotherapy and Udenyca is 
needed. The Plan denied your request. The Plan says that the use of Udenyca with a low-risk cancer treatment 
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 Udenyca. Our reviewer says that the 
documentation does support that Udenyca is reasonable and necessary for this enrollee. Our physician reviewer 
found the requested use of Udenyca (Q5111) is FDA-approved for the enrollees diagnosis. Our reviewer found 
that the risk of neutropenic fever is likely greater than 20% given the enrollee's age, prior chemotherapy, and 
risk of lurbinectedin. Our physician reviewer also found that the documentation does support that Udenyca is 
safe and effective for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Udenyca have been met. Therefore, we decided that the Plan has to pre-approve 
Udenyca (Q5111).  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tecentriq. 
 
You asked the Plan to pre-approve Tecentriq. You say that the enrollee received this drug prior to this request, 
and then changed insurance companies. You also say that you are prescribing consolidation immunotherapy, 
which would be better tolerated than 1 or 2 more cycles of platinum-based chemotherapy. The Plan denied 
your request. The Plan says chart notes support limited stage disease. The Plan also says the Part B Cancer 
compendia were reviewed, and unable to find support of Atezolizumab in Limited stage disease, it only has 
support for extensive stage. 
 
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 Tecentriq. Our reviewer says that 
Tecentriq is not medically reasonable and necessary for the enrollee. Our physician reviewer found the 
requested use of Tecentriq is not FDA-approved for the enrollees diagnosis. Our reviewer found that Tecentriq 
is approved for extensive stage, and the enrollee has limited stage. The use is not supported by one of the major 
drug compendia or by clinical research that appears in a Centers for Medicare and Medicaid Services approved 
medical journal. Our physician reviewer also found that the use is not listed as not indicated, not supported or 
not recommended in any of the compendia. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Tecentriq have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Tecentriq.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Optimizer Smart implantable pulse generator (0408T). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the clinical value and effectiveness of the Optimizer Smart implantable 
pulse generator device has not been demonstrated in the peer-reviewed literature. 
 
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 Optimizer Smart device (CCM) remains the subject of multiple studies examining long-term 
efficacy, as well as randomized, controlled, double-blinded trials to quantify clinical efficacy. Until such 
statistically rigorous studies are completed, it is premature to presume clinical outcomes and benefit. At the 
current time, our physician reviewer would not consider the CCM system to be medically necessary in this 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Optimizer Smart implantable pulse generator (0408T).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve a continued acute inpatient mental health stay. 
 
You asked the Plan to pre-approve a continued acute inpatient mental health stay. You say that the enrollee has 
remained a patient at the facility and has not been discharged as of December 13, 2022, due to continued need 
of psychiatric services until stabilized. The Plan denied your request. The Plan says that the requested acute 
inpatient mental health admission is not medically necessary as the submitted clinical information does not 
meet the Plan's Clinical Review Criteria. The Plan also says the submitted clinical documentation fails to 
indicate that the enrollee's needs require continuous (24 hours per day) skilled nursing care, daily medical care, 
and the availability of psychiatrists and physicians in other specialties 24 hours per day. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 continued acute inpatient mental 
health stay. Our reviewer says that the Plans denial of inpatient psychiatric services is inappropriate. Our 
physician reviewer found it was expected this enrollee would improve in a reasonable period of time as 
although she did not have dangerousness to self or others and was not showing any auditory/visual 
hallucinations she did have aggressive behaviors. It did appear medically necessary and reasonable to have 
psychiatric care provided at the acute inpatient level of care rather than a lower level of care. Our reviewer 
found that active treatment was taking place, and the services were reasonably expected to improve the 
enrollees condition or for the purpose of diagnosis. This enrollee was treated under an individualized treatment 
plan found in the record. Our physician reviewer also found that it did appear that the records were supervised 
and evaluated by a physician. 
 
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 continued acute inpatient mental health stay have been met. Therefore, we 
decided that the Plan has to pre-approve a continued acute inpatient mental health stay.  
 
  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 hyperbaric oxygen therapy (HBOT). 
 
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 HBOT is covered for specific indications only. 
 
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 is noted to have a 
multifactorial lower extremity ulcer. The enrollee has not yet maximized standard therapy, including being 
established on a statin and stopping smoking. The ulcer is largely due to vascular insufficiency, a condition for 
which HBOT is not covered. 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 hyperbaric oxygen therapy (HBOT).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Minuteman procedure (22612, 22840), to be provided 
by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a Minuteman procedure. You say that the service is medically necessary. 
The Plan denied your request. The Plan says the requested provider is out-of-network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a Minuteman procedure (22612, 22840), to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography (CT) of the thorax (71260) and CT of the 
abdomen and pelvis (74177). 
 
You asked the Plan to pre-approve a CT of the thorax and CT of the abdomen and pelvis. You say that the 
enrollee has had labs, x-rays, and other interventions completed without success. The Plan denied your request. 
The Plan says that these CT scans are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 CT of the thorax and CT of the 
abdomen and pelvis. Our reviewer says that the CT scans are reasonable and necessary for the enrollee. Our 
physician reviewer found the CT of the chest, abdomen and pelvis were ordered due to the enrollee's night 
sweats and elevated labs including erythrocyte sedimentation rate, C-reactive protein and Neurtrophil counts. 
Our reviewer found possible collagen vascular disease, but lymphoma would be in the differential as well. Our 
physician reviewer also found that based upon the history of night sweats and elevated inflammatory 
serological markers, the requested CT of the chest, abdomen and pelvis should be approved. 
 
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 CT of the thorax and CT of the abdomen and pelvis have been met. Therefore, 
we decided that the Plan has to pre-approve a computed tomography (CT) of the thorax (71260) and CT of the 
abdomen and pelvis (74177).  
 
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.