Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency department services (procedure code 99285) 
rendered on November 4, 2022. 
 
 
You asked the Plan to pay for the services. You say that you would like reconsideration of this downcoding. 
The Plan denied your request. The Plan says CPT 99285 was downcoded to CPT 99284. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99285 is "Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with 
other physicians, other qualified health care professionals, or agencies are provided consistent with the nature 
of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high 
severity and pose an immediate significant threat to life or physiologic function." 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that in this case, the documentation 
does not support the CPT code 99285. The documentation available for review does not support that the 
presenting problems were of high severity or that the medical decision was of high complexity. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for emergency department services (procedure code 99285) rendered on November 4, 2022.
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 the enrollee needs skilled nursing with physical 
therapy. The enrollee needs this therapy to get his strength back so they can eventually live at home. The Plan 
denied your request. The Plan says ongoing skilled care can be provided in an alternative setting. 
 
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 the member is an 84-year-old male with a medical history including osteoarthritis and 
hypertension who was admitted to the hospital after a fall resulted in acute kidney injury and rhabdomyolysis. 
He has been treated medically and improved. The most recent therapy documentation indicates the member is 
able to ambulate up to 250 feet without hands on assistance. 
 
The member has stabilized medically and is ready for discharge from the hospital.  The member does not 
require skilled nursing and/or skilled therapy services on a daily basis. He is medically stable and can receive 
further rehab services at a lower level of care. Although further rehab services would be appropriate to improve 
function, as a practical matter, 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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve the acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee requires an inpatient 
admission. The Plan denied your request. The Plan says that the requested inpatient admission is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that the review has determined that the record showed that at the time of inpatient 
admission the admitting physician reasonably expected that the enrollees necessary hospital care would span 
two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pre-approve the acute inpatient hospital care.  
 
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 you would like to request 
reconsideration of the denied authorization. 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 enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. All medically necessary care is being provided in 
the current acute care setting. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says that the requested SNF admission 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 considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the clinical documentation shows the enrollee has had clinical/functional status 
change thus would require skilled nursing/therapy assessment. The evaluation therapists recommend ongoing 
skilled therapy in a SNF. The clinical documentation shows that daily services on an inpatient basis in a SNF 
are 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 SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve SNF care.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee never left the hospital and went straight 
to a SNF. The Plan denied your request. The Plan says that the admission to a SNF 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 that the enrollee did not require daily skilled nursing or rehabilitation services at an 
inpatient level of care. As a practical matter, the enrollee did not require daily skilled services on an inpatient 
basis, at a SNF level of care at the time of discharge from the hospital. 
 
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 SNF care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-Melanoma test provided on September 14, 
2022 
 
You asked the Plan to pay for the DecisionDx-Melanoma test. You say that this is an approved test that was 
ordered by the enrollee's treating physician to inform treatment decisions. The Plan denied your request. The 
Plan says there is no documentation before molecular testing that the enrollee's melanoma was Stage T1b or 
T1a with documented concern about adequacy of micro staging. 
 
The Plan follows Medicare rules. Medicare rules say that this testing is covered when the enrollee has a 
personal history of melanoma and either Stage T1b and above OR has Stage T1a with documented concern 
about adequacy of micro staging. 
 
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 DecisionDx-Melanoma test. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the documentation shows that the enrollee's melanoma was stage T1a without concern about accuracy of micro staging. Thus, the 
enrollee does not meet the criteria for coverage. 
 
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 DecisionDx-Melanoma test have not been met. Therefore, we decided that 
the Plan does not have to pay for the DecisionDx-Melanoma test provided on September 14, 2022
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied 
your request. The Plan says that the enrollee has no skilled medical needs. 
 
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 that the enrollee does not require daily skilled nursing and/or skilled therapy services. 
The enrollee is medically stable and can receive further rehabilitation 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for air ambulance services provided on October 11, 2021. 
 
 You asked the Plan to pay for air ambulance services. You say that the medical records provided support the 
need for the air ambulance transport. The Plan denied your request. The Plan says the air ambulance services 
were not medically necessary. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 air ambulance services. Our reviewer says 
that the air ambulance transport service was not medically necessary. Our physician reviewer found the 
enrollee required surgical evaluation for a recurrent rectal prolapse. While transfer for services not locally 
available, the use of an air ambulance does not appear to have been medically necessary. Furthermore, the 
enrollee does not appear to have been transported to the nearest, appropriate 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 air ambulance services have not been met. Therefore, we decided that the Plan 
does not have to pay for air ambulance services provided on October 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the visual field exam and the office visit 
provided from November 14, 2022, to November 21, 2022. 
 
You asked the Plan to waive the copayments for the visual field exam and the office visit. You say that you 
should not pay a $40 copayment for a simple test that could have been done the prior week. The Plan denied 
your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for a $40 copayment for each in-network specialist's office visit.  
 
You have been asked to pay a $40 copayment for the visual field exam and the office visit on each date of 
service. These services fall within the vision care benefit category. Please note, the visual field exam is considered a physician service. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayments for the visual field exam and 
the office visit provided from November 14, 2022, to November 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that you would like to request reconsideration of 
the denied claim. The Plan denied your request. The Plan says this item is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a carotid doppler scan. 
 
You asked the Plan to pre-approve a carotid doppler scan. You did not provide a specific argument with this 
request. The Plan denied your request. The Plan says the provided medical records do not show that the 
member has had intermittent problems with his vision, or dysarthria, or hemibody weakness that resolved 
within 24 hours. In addition, there is no evidence that he had a carotid procedure and needs follow up with a 
duplex study. There is no description of abnormal results of previous duplex or that during the physical exam 
his doctor detected a carotid bruit. 
 The Plan follows Medicare rules. Medicare rules say that non-invasive vascular studies are considered 
medically necessary if the ordering physician has reasonable expectation that their outcomes will potentially 
impact the clinical management of the patient. 
 
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 carotid doppler scan. Our reviewer 
says that the requested carotid doppler scan is not medically necessary. Our physician reviewer found the 
enrollee is a  65-year-old male with diagnosis of hypertension. diabetes mellitus, dyslipidemia, diverticulosis, 
mild normocytic anemia, right sciatic pain (severe L5-S1 stenosis), and coronary artery disease. In January of 
2023, the patient went to the hospital complaining of chest pain, shortness of breath, nausea, and fatigue. The 
patient's electrocardiogram and chest x-ray were nondiagnostic. You are requesting carotid doppler to 
determine the cause of symptoms. On Sept. 2, 2022, the member had an unremarkable bilateral lower extremity 
(BLE) arterial duplex. On March 4, 2023, the right lower extremity Doppler was negative for deep vein 
thrombosis. In this case, there is no specific clinical rationale for the requested duplex scan of the extracranial 
arteries. 
 
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 carotid doppler scan have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a carotid doppler scan.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ziextenzo (pegfilgrastim-bmez). 
 You asked the Plan to pre-approve the requested treatment with Ziextenzo. You say that the enrollee requires 
this treatment. The Plan denied your request. The Plan says one of the preferred drugs can meet the enrollee's 
needs. 
 
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 requested treatment with Ziextenzo. 
Our reviewer says that the requested drug is not medically necessary based on step therapy criteria. Our 
physician reviewer found the Plan requires a trial of drug Neulasta, Neulasta OnPro, or Udenyca before they 
will approve the requested drug. In this case, the patient has not tried and failed the required drug(s). There is 
no documentation provided indicating that the plans required drug(s) 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 requested treatment with Ziextenzo have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Ziextenzo (pegfilgrastim-bmez).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the pneumatic compression device. You say that the provider is the only one 
in the enrollee's geographical area that can provide this equipment. The Plan denied your request. The Plan says 
the equipment can be provided by network providers. 
 
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 pneumatic compression device to be provided by an out-of-network (OON) provider.