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

 
We decided that the Plan does not have to pre-approve Hizentra (J1559). 
 You asked the Plan to pre-approve Hizentra. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says the enrollee has not tried and failed at least one of the preferred drugs, 
Gammagard, Gamunex-C, or Privigen. 
 
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 Hizentra. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the provided documentation indicates 
that the enrollee has not tried and failed the preferred drugs, Gammagard, Gamunex-C, or Privigen. The 
reviewer also found that there is no documentation provided indicating that the Plan's required drugs would 
likely be less effective and/or likely have adverse effects for the enrollee. Therefore, the reviewer found that the 
step therapy criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Hizentra have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Hizentra (J1559).
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says that the stay is not medically necessary based on SNF criteria. 
 
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 the clinical documentation shows that the enrollee has had clinical and functional 
status change thus would be expected to require ongoing assessment and treatment by skilled nursing and 
skilled therapy. The clinical documentation shows that the enrollee's past level of function was modified 
independent with mobility and now requiring max assist with transfers and bed mobility thus significantly 
beneath functional baseline and evaluating therapists along with primary team recommend daily skilled 
therapy. The clinical documentation shows that the enrollee would benefit from frequent skilled nursing 
assessment thus daily skilled services are supported. As a practical matter, the clinical documentation supports 
daily skilled services on an inpatient basis in 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 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 skilled nursing 
facility (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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Grafix PRIME, Stravix, and StravixPL skin substitutes. 
 
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 venous stasis ulcers of 
the lower extremity but not from diabetes. The wounds in the most recent note are described as improving 
(development of granulation tissue and decrease in size). The skin substitutes are not reasonable or medically 
necessary at this time, based on the submitted records. 
 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 Grafix PRIME, Stravix, and StravixPL skin substitutes.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit (procedure 99285) provided 
on July 6, 2023. 
 You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is not supported by the records. 
 
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 a medically appropriate history and/or examination and high level 
of medical decision making. 
 
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 service. Our reviewer found the Health Plans denial 
should be upheld. The enrollee was evaluated in the emergency department (ED) for shortness of breath. An 
appropriate history and physical were documented. The medical decision making was not of high 
complexity. As such, the billing of CPT 99285 is not supported. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pay for an emergency department visit (procedure 99285) provided on July 6, 2023.
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 requested IRF admission is medically necessary. 
The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the 
enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitation care. The enrollee was admitted for upper respiratory infection and 
acute on chronic renal insufficiency. Medical problems are stable. There are no complex nursing or 
rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, in an intensive rehabilitation therapy program. 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home health services. 
 You asked the Plan to pre-approve home health services. You say that  the services are medically necessary. 
The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the clinical 
documentation shows that you have right lower limb wounds requiring simple wound care but does not specify 
any complex wound care, acute clinical status, medication or plan of care changes thus the records do not show 
that home health skilled nursing services are required to effectively provide treatment, care, and/or services in 
order to improve your condition, or to establish/perform a maintenance program to maintain your condition 
and/or prevent deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the home health services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre Kit 2 continuous glucose monitor 
(CGM) system. 
 
You asked the Plan to pre-approve the CGM. You say that the enrollee's physician is appealing with medical 
records. The Plan denied your request. The Plan says  the enrollee is not on insulin and there are no 
documented hypoglycemia episodes. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the CGM. Our physician reviewer 
found the coverage criteria for CGM require insulin use or low blood glucose sugar (BGS). Our physician 
reviewer was not told of low BGSs, and the enrollee is taking a med that can cause low BGS, but none are 
noted. Therefore, although the CGM may help the enrollee, coverage criteria for CGM are not met. Our 
physician reviewer is also not told why a fingerstick meter would not suffice. 
 
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 CGM have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a Freestyle Libre Kit 2 continuous glucose monitor (CGM) system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Freestyle Libre 2 continuous glucose monitor 
(CGM) system. 
 
You asked the Plan to pre-approve the CGM. You say that the enrollee's physician is appealing with medical 
records. The Plan denied your request. The Plan says the enrollee is not on insulin and there are no documented 
hypoglycemia episodes. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the CGM. Our physician reviewer 
found the coverage criteria for CGM require insulin use or low blood glucose sugar (BGS); our physician 
reviewer was not told of low BGS, and the enrollee is taking a med that usually does not cause low BGS. 
Therefore, although the CGM may help the enrollee, coverage criteria for the CGM are not met. Our physician 
reviewer was not told why a fingerstick meter would not suffice. 
 
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 CGM have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Freestyle Libre 2 continuous glucose monitor (CGM) system.
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 enrollee needs this level of care. The 
Plan denied your request. The Plan says the enrollee's condition does not meet the criteria for an 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 the enrollee appears to be gradually improving with current treatment and should 
only require short-term additional acute care services that can safely be provided at the current facility until 
more stable and appropriate for transfer to a lower level of care. The enrollee does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the 
enrollee requires that are not already available and covered at the current facility. Transfer to the LTACH is not 
medically necessary as it would not be clinically advantageous at this time. Completion of treatment at the 
current facility is 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 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit (procedure 99285) provided 
on May 16, 2023. 
 You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is not supported by the records. 
 
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 a medically appropriate history and/or examination and high level 
of medical decision making. 
 
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 service. Our reviewer found the Health Plans denial 
should be upheld. The enrollee was evaluated in the emergency department (ED) after falling and striking her 
head and forearms. Imaging was obtained and the enrollee was discharged. A limited history of the present 
illness is documented, but a full medical history is absent. An appropriate physical examination is documented. 
The medical decision making was not of high complexity. As such, the billing of CPT 99285 is not supported. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pay for an emergency department visit (procedure 99285) provided on May 16, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve tacrolimus. 
 You asked the Plan to pre-approve the medication. You say that this is necessary for the enrollee, so they do 
not have rejection to their transplant. The Plan denied your request. The Plan says the medication is not 
covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Additionally, the record shows that the enrollees transplant took place prior to their 
enrollment in Medicare. Therefore, we decided that the Plan does not have to pre-approve tacrolimus.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye examination, the refraction, the gonioscopy, the 
special eye evaluation, the visual field examination, and the fundus photography provided on October 24, 2022, 
by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the vision services. You say that the services were medically necessary and 
should be paid. The Plan denied your request. The Plan says the provider was out-of-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the vision services. The Plan did not pre-approve the vision services. We 
found no exception that would require the Plan to pay for the vision services. Therefore, we decided that the 
Plan does not have to pay for the eye examination, the refraction, the gonioscopy, the special eye evaluation, 
the visual field examination, and the fundus photography provided on October 24, 2022, by an out-of-network 
(OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xF testing (81455) provided on June 27, 2023. 
 
You asked the Plan to pay for the Tempus xF testing. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the test is not covered. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Per review of the DEX Diagnostics Exchange, the Tempus xF test 
was reviewed through the MolDX process and coverage criteria has not been set for this test. Therefore, we 
decided that the Plan does not have to pay for the Tempus xF testing (81455) provided on June 27, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the short-latency somatosensory evoked potential study and 
continuous intraoperative neurophysiology monitoring billed with codes 95938 and 95940. 
 
You asked the Plan to pay for the tests. You say that the services were billed correctly and should be paid. The 
Plan denied your request. The Plan says  code 95938 is included in the facility payment and is not separately 
payable, as this code was reported with modifier TC, which is paid by the facility. In addition, code 95940 is an 
add-on code that can't be paid unless the primary procedure (95938) is also paid. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Technical components must be billed by the 
facility where the enrollee was in an inpatient or outpatient and are not separately payable to the lab. 
 
The records indicate that this service was provided to the enrollee while in an inpatient or outpatient facility. 
Per the Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code 95938. This 
means there is both a professional and technical component for this code. In this case, an appropriate modifier 
to indicate the professional component (-26) has not been billed with CPT code 95938. Based on this 
information, we decided that Medicare rules for coverage of this code have not been met. In addition, we have 
confirmed that code 95940 is an add-on code for code 95938, and the primary code was denied payment. Based 
on the claim submitted, Medicare billing criteria have not been met.  Therefore, we decided that the Plan does 
not have to pay for the short-latency somatosensory evoked potential study and continuous intraoperative 
neurophysiology monitoring billed with codes 95938 and 95940.