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

 
We decided that the Plan has to pre-approve a sacroiliac joint injection. 
 
You asked the Plan to pre-approve a sacroiliac joint injection. You say that the requested sacroiliac joint 
injection is medically necessary. The Plan denied your request. The Plan says that the requested sacroiliac joint 
injection is not medically necessary. 
 
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 a sacroiliac joint injection. Our 
reviewer says that the requested sacroiliac joint injection is medically necessary. Our physician reviewer found 
the enrollee has left sided sacroiliitis. She has 3 positive physical exam diagnostic tests. The pain has been 
present for 3 years. Her current medications include Oxycodone, Tizanidine, Topamax, Clonidine, 
Amitriptyline, Duloxetine, Gabapentin, and Lidocaine/Prilocaine cream. The request is medically reasonable 
and 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 sacroiliac joint injection have been met. Therefore, we decided that the Plan 
has to pre-approve a sacroiliac joint injection.  
 
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 LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH services are medically 
necessary. The Plan denied your request. The Plan says that the coverage criteria has 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 that the record indicates that the enrollee is improving but still requires acute care 
services before transitioning to a lower level of care. The enrollee continues to receive acute care services, and 
these have not been denied. The medical record does not indicate that the enrollee requires services that they 
are not currently receiving but that would be available at the LTACH facility. 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 LTACH 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 it is felt that this IRF stay is needed. The Plan denied 
your request. The Plan says you prefer to be admitted to an IRF so you can regain your independence. 
 
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 member is an 82-year-old female with a medical history including hypertension 
chronic lung disease and cardiac disease who was admitted to the hospital with increased shortness of breath. 
She was diagnosed and treated for multiple pulmonary emboli with right heart strain. She has had a complex 
hospital stay but has stabilized medically. The most recent therapy notes indicate that the member requires 
stand-by to minimal assistance for functional mobility and to ambulate. 
 
In this case, the complexity of the members nursing, medical and rehabilitation needs do not require an acute 
rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The member does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, at 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lupron. 
 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 that you have a diagnosis of prostate 
cancer. You have not tried and failed the Plan's required drug, Eligard. The records do not show that the 
required drug would have adverse effects or be less effective; therefore, Lupron 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 Lupron.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar laminectomy, spinal fusion, including associated 
procedures, implants supplemental bone products and hospital inpatient admission represented by procedure 
codes 20936, 22612, 20930, 22840, and 63047. 
 
You asked the Plan to pre-approve lumbar laminectomy, spinal fusion, including associated procedures, 
implants supplemental bone products and hospital inpatient admission represented by procedure codes 20936, 
22612, 20930, 22840, and 63047. You say that the requested lumbar laminectomy, spinal fusion, including 
associated procedures, implants supplemental bone products and hospital inpatient admission represented by 
procedure codes 20936, 22612, 20930, 22840, and 63047 is medically necessary. The Plan denied your request. 
The Plan says the requested lumbar laminectomy, spinal fusion, including associated procedures, implants 
supplemental bone products and hospital inpatient admission represented by procedure codes 20936, 22612, 
20930, 22840, and 63047 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 lumbar laminectomy, spinal fusion, 
including associated procedures, implants supplemental bone products and hospital inpatient admission 
represented by procedure codes 20936, 22612, 20930, 22840, and 63047. Our reviewer says that the requested 
lumbar laminectomy, spinal fusion, including associated procedures, implants supplemental bone products and 
hospital inpatient admission represented by procedure codes 20936, 22612, 20930, 22840, and 63047 is not 
medically necessary. Our physician reviewer found there is no documentation of spinal segment instability on 
imaging studies. Spinal fusion surgery is not needed at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lumbar laminectomy, spinal fusion, including associated procedures, implants 
supplemental bone products and hospital inpatient admission represented by procedure codes 20936, 22612, 
20930, 22840, and 63047 have not been met. Therefore, we decided that the Plan does not have to pre-approve 
lumbar laminectomy, spinal fusion, including associated procedures, implants supplemental bone products and 
hospital inpatient admission represented by procedure codes 20936, 22612, 20930, 22840, and 63047.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (E0466). 
 
You asked the Plan to pre-approve the ventilator. You say that the ventilator is medically necessary. The Plan 
denied your request. The Plan says the ventilator is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the ventilator. Our physician reviewer 
found there is no arterial blood gas (ABG) done while stable, after correction of the hypothyroid state, to document chronic carbon dioxide (CO2) retention. If that is present, the enrollee's diagnosis is most likely 
obesity hypoventilation syndrome, and the enrollee may benefit from continuous positive airway pressure 
(CPAP) or bilevel positive airway pressure (BiPAP) during sleep as an outpatient. Medicare does not cover a 
home ventilator for the treatment of obesity hypoventilation syndrome, or when used at settings that can be 
provided with BiPAP. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the home ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMs Heart Failure (HF) system. 
 
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 CardioMEMs device was approved 
by the Food and Drug Administration (FDA) in 2014. Nonetheless, there remains a dearth of randomized, 
blinded clinical studies examining long-term clinical outcomes establishing the value of CardioMEMS in 
patient management. As a result, at this time the CardioMEMS system would not be considered medically 
appropriate and necessary in the enrollee's 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a CardioMEMs Heart Failure (HF) system.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Supartz injections. 
 
You asked the Plan to pre-approve the Supartz injections. You say that it is felt that this treatment is needed. 
The Plan denied your request. The Plan says the requested drug is not medically necessary. 
 
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 Supartz injections. Our reviewer 
says that the documentation does not support the medical necessity of this treatment at this time. Our physician 
reviewer found the record indicates that the enrollee has a diagnosis of osteoarthritis of the knee. The record 
provided does not demonstrate that the enrollee has had a recent trial pf physical therapy and failed. The record 
indicates that the enrollee had improvement in symptoms with a brief trial of physical therapy in 2021. The 
Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's condition 
without a trial of physical therapy. The Medicare approved drug compendia do not contain a supportive citation 
for the use of the requested drug in the enrollee's clinical situation. The elements of the coverage criteria are not 
satisfied.  
 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 Supartz injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Supartz injections.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve bevacizumab-awwb, biosimilar, (Mvasi). 
 
You asked the Plan to pre-approve bevacizumab-awwb, biosimilar, (Mvasi). You say that the requested 
bevacizumab-awwb, biosimilar, (Mvasi), is medically necessary. The Plan denied your request. The Plan says 
that the requested bevacizumab-awwb, biosimilar, (Mvasi), 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 bevacizumab-awwb, biosimilar, 
(Mvasi). Our reviewer says that the requested bevacizumab-awwb, biosimilar, (Mvasi), is medically necessary. 
Our physician reviewer found the requested use of bevacizumab-awwb is FDA-approved for the enrollee's 
diagnosis. Increase in size of cecal mass does not meet RECIST criteria for progression and, therefore, the 
enrollee is considered to have stable disease. The documentation supports that the requested drug is safe and 
effective and otherwise reasonable and necessary for 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 bevacizumab-awwb, biosimilar, (Mvasi) have been met. Therefore, we decided 
that the Plan has to pre-approve bevacizumab-awwb, biosimilar, (Mvasi).  
 
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 a sacroiliac (SI) joint injection. 
 
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 has chronic low back and 
hip pain with spinal stenosis. There is no physical examination of the SI joint in the documentation. There is no 
documentation identifying the SI joint as the source of her pain. The requested SI joint is therefore not 
reasonable or medically necessary at this time. 
 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 a sacroiliac (SI) joint injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
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. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the criteria for coverage are not met. Our physician reviewer found the records show that you have chronic respiratory failure and shallow breathing (hypoventilation syndrome). You also have dysfunction of the 
diaphragm. The records do not support that you meet the criteria for coverage of the home ventilator. The 
services are therefore not reasonable or medically necessary at this time. 
 
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 a home ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (E0466). 
 
You asked the Plan to pre-approve the ventilator. You say that the ventilator is medically necessary. The Plan 
denied your request. The Plan says the ventilator is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the ventilator. Our physician reviewer 
found there is no arterial blood gas (ABG) done while stable to confirm chronic carbon dioxide (CO2) retention. If that is present, the enrollee may benefit from bilevel positive airway pressure (BiPAP) with 
average volume-assured pressure support (AVAPS) during sleep as an outpatient. Medicare does not cover a 
home ventilator when used at settings that can be provided with BiPAP. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the home ventilator (E0466).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you are requesting reconsideration for the denial of 
a continued SNF stay. The Plan denied your request. The Plan says the request for continued SNF services is 
not medically necessary. 
 
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 care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
Although further rehabilitation services would be appropriate to improve function, the intermittent skilled 
services can be provided at a lower level of care than a skilled nursing facility. 
 
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 care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity (J3111). 
 You asked the Plan to pre-approve Evenity. You say that you would like Evenity to be approved as a first line 
agent in the treatment of this enrollee's osteoporosis. The Plan denied your request. The Plan says the enrollee 
does not have any stated contraindications to the preferred products. The Plan also says the enrollee has not 
tried any of the preferred agents. 
 
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 Evenity. Our reviewer says that the 
enrollee does not meet the coverage criteria for Evenity. Our physician reviewer found there is no indication 
that the enrollee has tried and failed the required drugs. Our reviewer also found that there is no indication that 
the Plan's required drugs 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 Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Evenity (J3111).