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

 
We decided that the Plan does not have to pre-approve Evenity 105MG/1.17ML (J3111). 
 You asked the Plan to pre-approve the drug. You say that the drug is medically 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: Forteo, or that the enrollee has 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 drug. Our physician reviewer found 
the Plan requires a trial of drug Forteo before they will approve the requested drug. In this case, the enrollee 
has not tried and failed the required drug(s). There is no documentation provided indicating that the Plan's 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Evenity 105MG/1.17ML (J3111).
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve the Nulojix (J0485). 
 
You asked the Plan to pre-approve the medication. You say that the medication is needed under home infusion 
in order to prevent the rejection of the kidney transplant.  The Plan denied your request. The Plan says that the 
requested medication does not meet criteria for coverage.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 the medication. Our physician reviewer 
found the enrollee is stable on Nulojix for over a year. Given how well the enrollee has tolerated the 
medication, our physician reviewer states they do not anticipate any issues with home infusion. In fact, home 
infusion would put the enrollee at a lower risk for infectious complications based on not being exposed to as 
many people at an infusion center like setting. Any safety concerns should be offset by the over a year long 
experience in tolerating the medication. Our physician reviewer believes the drug to be safe and effective. 
 
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 the Nulojix (J0485).  
 
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 Yervoy (J9228), Opdivo (J9299), methylprednisolone sodium 
succinate (J2930), Famotidine (J3490), Epinephrine (J0171), Diphenhydramine (J1200), hydrocortisone 
Sodium Succinate (J1720). 
 
You asked the Plan to pre-approve the medication. You say that the medication is medically necessary. The 
Plan denied your request. The Plan says that the medication 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 medication. Our physician reviewer 
found the requested use of drugs are FDA-approved for the enrollees diagnosis. Ivolumab and Ipilimumab 
combination was approved by FDA for the treatment of patients with nonsmall cell lung cancer in metastatic 
or recurrent non-small cell lung cancer (NSCLC) with tumors that have PD-L1 expression greater than or equal 
to 1 percent and with no estimated glomerular filtration rate (EGFR) or anaplastic lymphoma kinase (ALK) 
genomic tumor mutations. The Checkmate-227 trial has documented this to be safe and effective. 
 
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 Yervoy (J9228), Opdivo (J9299), methylprednisolone sodium succinate (J2930), Famotidine (J3490), 
Epinephrine (J0171), Diphenhydramine (J1200), hydrocortisone Sodium Succinate (J1720).  
 
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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires acute physical and occupational 
rehabilitation services prior to returning home safely due to weakness and deconditioning status post fall. You 
say the enrollee requires peritoneal dialysis treatments daily which has resulted in multiple skilled nursing 
facility denials. The Plan denied your request. The Plan says the enrollee does not meet the medical necessity 
criteria for admission to an IRF. 
 The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports 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. 
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 38 visits of physical therapy (PT) services.  
 
You asked the Plan to pre-approve the PT services . You say that the services are medically necessary for you 
to continue with your care as you still having difficulty. The Plan denied your request. The Plan says a review 
of the current medical literature indicates that the average number of physical therapy visits for your condition 
is about 12 visits, which were previously approved.   
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 PT services. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found PT is not medically necessary to maintain a repetitive exercise 
program for knee arthritis.  
 
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 PT services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 38 visits of physical therapy (PT) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on November 14, 2022, 
to November 15, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
enrollee presented with the clinical indicators for sepsis and the correct DRG should be reimbursed.  The Plan 
denied your request. The Plan says payment of DRG 871 is not supported.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with A41.9 - sepsis unspecified organism. 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 pay for the inpatient hospital services at the DRG originally billed. 
Our physician reviewer found the Health Plans denial should be upheld. The enrollee presented with a fever. 
The enrollee was found to have pneumonia. The enrollees blood pressure was low, but the enrollee was 
asymptomatic, and the enrollee's blood pressure was noted to improve with intravenous (IV) fluids. There is no 
evidence of hypoperfusion or organ failure. As such, a diagnosis of sepsis is not supported.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on November 14, 2022, to November 15, 2022, at the Diagnosis 
Related Group (DRG) originally billed.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Darzalex. 
 
You asked the Plan to pre-approve Darzalex. 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 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 Darzalex. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found this medication is not FDA-approved for 
this diagnosis. Although DrugDex lists the drug with Grade B evidence to support its use for AL amyloidosis, 
there was no quality study referenced with both Darzalex and Kyprolis in a trial showing safety and efficacy to sufficiently support this enrollee's clinical situation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Darzalex have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Darzalex.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the facial feminization surgery (30420, 30410, 67900). 
 
You asked the Plan to pre-approve the surgical services. You say that this is medically necessary because of 
life-threatening distress. The Plan denied your request. The Plan says this is not being requested to improve 
nasal respiratory function.  
 The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
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 surgical services. Our reviewer 
found the records do not indicate the presence of visual impairment or respiratory dysfunction due to nasal 
obstruction. The record provided is insufficient to establish the medical necessity of the requested service. The 
record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of 
the requested service. 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 the surgical services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the facial feminization surgery (30420, 30410, 67900).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve radiofrequency ablation (64626). 
 
You asked the Plan to pre-approve a genicular nerve radiofrequency ablation. You say that the services are 
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 
coverage criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a genicular nerve radiofrequency 
ablation. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the review has determined that the requested 
radiofrequency ablation of the genicular nerve for chronic knee pain 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 a genicular nerve radiofrequency ablation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a genicular nerve radiofrequency ablation (64626).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lupron depot 45MG kit (J9217, 96402). 
 You asked the Plan to pre-approve the medication. You say that the enrollee has prostate cancer and needs to 
start hormone therapy. Your office does not carry Eligard.  The Plan denied your request. The Plan says the 
enrollee has not tried and failed the preferred drug Eligard.  
 
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 Plan requires a trial of Eligard before they will approve the requested drug. The enrollee has not tried 
and failed the required drug. The documentation does not support that Eligard would likely be less effective, 
and/or would likely have adverse effects for the enrollee 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 the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Lupron depot 45MG kit (J9217, 96402).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on November 30, 2022, 
to December 6, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that these 
services and diagnoses were reported correctly and are supported in the medical records. The Plan denied your 
request. The Plan says the diagnosis of sepsis, unspecified organism (A41.9) is not supported in the medical 
record. This means that payment of DRG 871 is not supported, though payment for DRG 193 may be 
appropriate. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with sepsis, unspecified organism (A41.9). 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 pay for the inpatient hospital services at the DRG originally billed. 
Our reviewer says that this diagnosis is not supported in the medical record. Our physician reviewer found the 
documentation does not consistently and completely support the assigned principal diagnosis code with DRG. 
The replacement of DRG is upheld as it is supported by the medical documentation.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on November 30, 2022, to December 6, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve PancraGen genetic testing (81479). 
 
You asked the Plan to pre-approve PancraGen. You say that this testing is medically necessary. The Plan 
denied your request. The Plan says this test is not medically necessary or appropriate for this enrollee. 
 
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 PancraGen. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the record indicates that the enrollee underwent biopsy of the distal esophagus and cystic 
pancreatic lesions on June 2, 2023. There is a pancreatic cystic lesion measuring 36mm which was non-
diagnostic on biopsy. Another pancreatic cyst measuring 7mm demonstrating findings atypical mucinous 
epithelium with low grade cytologic atypia. Biopsy records also indicate carcinoembryonic antigen (CEA), amylase, and glucose testing were ordered on the samples, but these results were not provided. In this case, the 
records do not show evidence of pancreatic duct enlargement or an elevated CEA level. The review has 
determined that the items/services at issue in this case are 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 PancraGen have not been met. Therefore, we decided that the Plan does not 
have to pre-approve PancraGen genetic testing (81479).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a K3 foot and high activity knee frame (L5930, L5981, 
L5986). 
 You asked the Plan to pre-approve a K3 foot and high activity knee frame. 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 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 K3 foot and high activity knee frame. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found the 
documentation does not reveal vocational or avocational activities that support that this patient requires a high 
activity knee control frame or an advanced foot with ankle feature. The requested  L5968, L5981, L5930 
exceed the enrollee's functional and medical needs and are not supported by the documentation. The criteria for 
these items have not been met per L33787 and per Social Security Act, Section 1862 (a)1(A) and the 42 CFR 
411.15(k). 
 
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 K3 foot and high activity knee frame have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a K3 foot and high activity knee frame (L5930, L5981, 
L5986).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) and 
supplies (A7030, A4604, E0562, E0601). 
 You asked the Plan to pre-approve CPAP and 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 continued coverage of a PAP device (E0470 or 
E0601) beyond the first three months of therapy requires that, no sooner than the 31st day but no later than the 
91st day after initiating therapy, the treating practitioner must conduct a clinical re-evaluation and document 
that the beneficiary is benefiting from PAP therapy. 
 
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 CPAP and supplies. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found continuation of CPAP is not 
medically necessary. The notes in the medical record indicate that you have had trouble tolerating and using the 
device. You indicate in a note on May 11, 2023, that you are not using the device. Reasonable efforts have 
been made to achieve tolerance. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CPAP and supplies have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a continuous positive airway pressure (CPAP) and supplies (A7030, A4604, E0562, 
E0601).