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

 
We decided that the Plan does not have to pre-approve Aranesp. 
 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 anemia of chronic 
kidney disease. He has not tried and failed the Plan's required drugs, Retacrit or Procrit. The records do not 
show that the required drugs would be contraindicated or less effective; therefore, Aranesp 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 Aranesp.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ozurdex injection (J7312). 
 
You asked the Plan to pre-approve the medication. You say that you need this medication and have been 
getting it every 3 months in the left eye because I have no vision in your right eye. The Plan denied your 
request. The Plan says this request cannot be approved at this time. 
 
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 reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found in this case the record indicates that the enrollee has a diagnosis of glaucoma. The Food and 
Drug Administration has stated that the requested drug is indicated for the enrollee's condition. The record 
provided does not document that the previous administration of the requested drug was efficacious or the 
medical necessity for a repeat administration at this time. The elements of the coverage criteria are not 
satisfied. The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Ozurdex injection (J7312).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat epidural steroid injection (ESI) (62321). 
 
You asked the Plan to pre-approve a repeat ESI. You say that this is medically necessary for the enrollee. The 
Plan denied your request. The Plan says the records show the enrollee did not have 50% pain relief from the 
first ESI. 
 
The Plan follows Medicare rules. Medicare rules say that a repeat ESI when the first injection directly and 
significantly provided improvement of the condition being treated may be considered medically reasonable and 
necessary when the medical record documents at least 50% of sustained improvement in pain relief and/or 
improvement in function measured from baseline using same scale for at least 3 months. 
 
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 repeat ESI. Our reviewer says that the 
requested repeat ESI is not medically necessary. Our physician reviewer found the provided documentation 
does not reveal over 50% pain relief from the initial cervical epidural steroid injection. The documentation does 
not reveal that the second epidural steroid injection will be performed using a new approach, level or 
medications. The documentation does not reveal subjective of objective findings of cervical radiculopathy. The 
documentation does not reveal clear failure of conservative management. Therefore, the reviewer found that the 
requested ESI 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 repeat ESI have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a repeat epidural steroid injection (ESI) (62321).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PET scan with CT scan. 
 
You asked the Plan to pre-approve a PET scan with CT scan. The Plan denied your request. The Plan says a 
PET scan with CT scan is not medically necessary.  
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 PET scan with CT scan. Our reviewer 
says that a PET scan with CT scan is not medically necessary. Our physician reviewer found that an abdomino-
pelvic computed tomography (CT) scan or bone scan should not routinely be performed in asymptomatic 
patients with low- or intermediate-risk prostate cancer. Alternate imaging should be performed for patients with 
high-risk prostate cancer and patients with prostate cancer at high risk for 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 a PET scan with CT scan have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a PET scan with CT scan.
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 the LTACH admission is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet the criteria of the LTACH 
admission. 
 
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 evidence that the enrollee requires services that are not currently available.  
As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the 
enrollee to the LTACH.  The enrollee can remain at the current ACH until such time no acute services are 
required.  The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term 
care needs. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Sprint PNS System. 
 
You asked the Plan to pre-approve a Sprint PNS System. You say that the enrollee has chronic intractable left 
shoulder pain. The Plan denied your request. The Plan says medical studies haven't proven this service/item is 
helpful for the treatment of the enrollee's health problem.  
 
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 Sprint PNS System. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the SPRINT PNS device is experimental for shoulder 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 a Sprint PNS System have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Sprint PNS System.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Fulphila. 
 You asked the Plan to pre-approve Fulphila. You say that the enrollee has already started their first round of 
chemotherapy. The Plan denied your request. The Plan says that the step therapy requirements have not been 
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 Fulphila. Our reviewer says that 
Fulphila is not medically necessary. Our physician reviewer found that the enrollee has not tried and failed the 
Plan's required drugs Neulasta and Udenyca. Also, there is no indication that the Plan's requires drugs would 
likely be less effective or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Fulphila have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Fulphila.
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 meets IRF criteria and requires intensive 
inpatient rehabilitation with daily physician management, continuous specialized rehabilitation nursing, and 
intensive therapies to optimize mobility an strengthening while ensuring the restoration of functional status for 
a safe and sustainable discharge. You also say the enrollee's needs cannot be safely met by skilled nursing or 
home health care. The Plan denied your request. The Plan says the notes do not show that the enrollee has 
complex care needs that require a coordinated team approach; the notes do not show that the enrollee must 
have an intensive therapy program (3 hours a day, at least 5 days a week) in order to improve self-care functioning.  
 
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 rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program. The enrollee continues to have a need for skilled 
therapy with ongoing safety concerns and a potential for functional improvement. However, the documentation 
does not support that the enrollee would meet criteria for admission to an IRF.  There is no indication that the 
enrollee would require skilled rehabilitation in an IRF, participating in rehabilitation services 15 hours a week, 
under the supervision of a physician with at least 3 visits weekly to regain or maintain their functional 
status.  The enrollee can receive further services at a lower 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve spinal fusion from L4 to S1. 
 
You asked the Plan to pre-approve spinal fusion. You say that you are appealing the denial. The Plan denied 
your request. The Plan says that the criteria for coverage 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 spinal fusion. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that detailed documentation regarding a trial and failure of recent, reasonable, comprehensive, 
less invasive conservative care measures is not evident. There is no indication of a completed course of therapy 
that has plateaued for improvement of symptoms. The enrollees medications are not clearly documented for 
the lower back symptoms, and there is no indication of injection therapies having been tried and failed.  More conservative treatments are typically recommended prior to invasive surgical procedures. Additionally, 
the recent exam did not corroborate any significant neurological deficits or a progression of these findings 
objectively. Dynamic flexion/extension films do not demonstrate movement (instability) at the requested 
surgical level. Detailed documentation is not evident regarding potential impending/inevitable temporary intra-
operative instability. There are limited large-scale, long-term references showing the safety and efficacy of the 
requested surgery in this clinical setting. There is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of spinal fusion have not been met. Therefore, we decided that the Plan does not 
have to pre-approve spinal fusion from L4 to S1.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex procedure. 
 
You asked the Plan to pre-approve Vertiflex procedure. 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 Vertiflex procedure. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the vertiflex devcie is 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 Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Vertiflex procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that you are requesting reconsideration due to 
medical necessity. The Plan denied your request. The Plan says the records do not include a standard written 
order for the requested ventilator and do not show adequate detailed information to meet Medicare criteria for 
coverage of a ventilator. 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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not 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 a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the record indicates that the enrollee 
has chronic respiratory failure from chronic obstructive pulmonary disease. The record indicates that the 
enrollee is being treated with 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 and failure of such a 
device has not been documented. 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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing 
provided on July 28, 2021. 
 
You asked the Plan to pay for the urine PCR panel testing. You say that this testing was medically necessary. 
The Plan denied your request. The Plan says the PCR testing is considered unproven and 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 pay for the urine PCR panel testing. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that this degree of testing was neither medically reasonable nor 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 urine PCR panel testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing provided on July 28, 
2021.
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 admission to the LTACH is a medical 
necessity.  The Plan denied your request. The Plan says based on Medicare guidelines, the long term acute care 
hospital services requested do not meet the requirements for approval.  
 
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 this is an enrollee with decompensated cirrhosis. The enrollee had a spinal epidural 
abscess requiring surgical procedures.  
 The enrollee does not require services at the LTACH that are not available at the acute care hospital where 
currently receiving care. Given there are offered alternatives, LTACH is not 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 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: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve renal allotransplantation. 
 
You asked the Plan to pre-approve renal allotransplantation. You say that the Plan's denial is based on incorrect 
information. The Plan denied your request. The Plan says that this is indicated when there is documentation of 
body-mass index (BMI) less than 33 and not smoking; however, the enrollee's BMI is 36.49. 
 
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 renal allotransplantation. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is clearly a transplant candidate. Transplantation before starting dialysis 
is encouraged and is standard practice. Body-mass index (BMI) of over 40 is typically the cutoff for denying 
transplantation and some center will transplant with a higher BMI. The enrollee is a non-smoker. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of renal allotransplantation have been met. Therefore, we decided that the Plan has 
to pre-approve renal allotransplantation.  
 
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.