Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant360 testing provided on May 6, 2020. 
 
You asked the Plan to pay for genetic testing. You say that the enrollee's treating physician ordered this testing 
to determine if there was a more effective therapy for the enrollee's condition. The Plan denied your request. 
The Plan says the denial of payment for this testing is correct, because this testing was not billed with the 
appropriate coding. 
 
The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing must be billed with CPT 
code 81479 for date of service May 6, 2020.  
 
We looked at the file and Medicare rules. This testing was not billed with the appropriate CPT coding. Based 
on this information, we decided that Medicare rules for coverage of genetic testing have not been met. 
Therefore, we decided that the Plan does not have to pay for Guardant360 testing provided on May 6, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
pneumonia. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. The medical record supports a need for physical and occupational 
therapy, but it does not support a need for an intensive rehabilitation therapy program. There is not a reasonable 
expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy 
program provided in an IRF. 
 
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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive genomic profile (CPG) testing provided on 
April 12, 2020. 
 
You asked the Plan to pay for genetic testing. You say that the enrollee's treating physician ordered this testing 
to determine if there was a more effective therapy for the enrollee's condition. The Plan denied your request. 
The Plan says the denial of payment for this testing is correct, because this testing was not billed with the 
appropriate coding. 
 
The Plan must follow Medicare rules. Medicare rules say that CGP testing must be billed with CPT code 81479 
for date of service April 12, 2020.  
 
We looked at the file and Medicare rules. This testing was not billed with the appropriate coding. Based on this 
information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we 
decided that the Plan does not have to pay for comprehensive genomic profile (CPG) testing provided on April 
12, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant360 testing provided on May 6, 2020. 
 
You asked the Plan to pay for genetic testing. You say that the enrollee's treating physician ordered this testing 
to determine if there was a more effective therapy for the enrollee's condition. The Plan denied your request. 
The Plan says the denial of payment for this testing is correct, because this testing was not billed with the 
appropriate coding. 
 
The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing must be billed with CPT 
code 81479 for date of service May 6, 2020.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for 
Guardant360 testing provided on May 6, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant360 testing provided on May 4, 2020. 
 
You asked the Plan to pay for genetic testing. You say that the enrollee's treating physician ordered this testing 
to determine if there was a more effective therapy for the enrollee's condition. The Plan denied your request. 
The Plan says the denial of payment for this testing is correct, because this testing was not billed with the 
appropriate coding. 
 
The Plan must follow Medicare rules. Medicare rules say that Guardant360 must be billed with CPT code 
81479 for date of service May 4, 2020.  
 
We looked at the file and Medicare rules. This testing was not billed with the appropriate CPT coding. Based 
on this information, we decided that Medicare rules for coverage of genetic testing have not been met. 
Therefore, we decided that the Plan does not have to pay for Guardant360 testing provided on May 4, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on July 11, 2019. 
 
You asked the Plan to pay for the Guardant360 testing. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the Guardant360 testing is not supported in the medical record. Specifically, this service should be 
coded with code 81479. In addition, the appropriate DEX Z code identifier should be entered adjacent to the 
code in the comment/narrative field. Based on this information, we decided that Medicare rules for coverage of 
the Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
Guardant360 testing provided on July 11, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 based on review of available records, the patient does not meet Medicare criteria for 
coverage for an IRF admission. The patient is medically stable but receiving chemo therapy with no evidence 
of complex medical issues that require monitoring by an inpatient Physical Medicine and Rehabilitation 
(PM&R) physician three times per week or need for acute rehab nursing care. At the patient's current 
endurance and functional level, they need therapies as tolerated but not in an IRF with high intensity. While the 
patient may benefit from continuing physical therapy (PT) and occupational therapy (OT), there is no evidence 
of need for an intensive therapy program with therapy 3 hours per day with frequent physician oversight and an 
interdisciplinary approach to rehabilitation care. The patient's medical monitoring has to be by Oncologists and 
not by physiatrists. Admission to IRF is not necessary based on the patient's low endurance and current 
functional status. The patient's rehab needs can be met at an alternate, low intensity level setting such as in-
home with services. 
 
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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for surgical services and Part B drugs provided 
on May 1, 2020. 
 
You asked the Plan to waive the copayment for surgical services and Part B drugs. You say that you have 
appealed for this service in previous years and been covered. The Plan denied your request. The Plan says the 
copayment you are being charged is correct. 
 
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 20% 
coinsurance for in-network Medicare-covered Part B Chemotherapy drugs and other Part B drugs and a $300 
copayment for each in-network Medicare-covered outpatient hospital facility visit for outpatient surgery.  
 
The allowed amount of the claim is $30.55, resulting in a coinsurance obligation of $6.11 for Part B drugs. You 
have also been asked to pay $242.72 for surgical services, which is less than your $300 copayment. Therefore, 
your total cost sharing responsibility is $248.83. Part B drugs fall within the Medicare Part B prescription drugs 
benefit category. Outpatient surgical services fall within the outpatient surgery, including services provided at 
hospital outpatient facilities and ambulatory surgical centers, benefit category. 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 copayment for surgical services and Part B drugs provided on May 1, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on April 20, 2020. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing must be reported with one 
unit of CPT 81479 and the appropriate DEX Z-Code.  
 
We looked at the file and Medicare rules. The requested Guardant360 testing was billed with multiple CPT 
codes. Per the applicable article, this testing must be reported with CPT 81479 and the appropriate DEX Z-
Code. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. 
Therefore, we decided that the Plan does not have to pay for the Guardant360 testing provided on April 20, 
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the crowns and bone replacement graft. 
 
You asked the Plan to pre-approve the crowns and bone replacement graft. The Plan denied your request. The 
Plan says the services are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
crowns and bone replacement graft.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve twelve (12) additional physical therapy sessions. 
 
You asked the Plan to pre-approve additional physical therapy sessions. You say that you are requesting 
physical therapy two times a week for eight weeks. The Plan denied your request. The Plan says additional 
visits are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve additional physical therapy sessions. 
Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent 
deterioration of the enrollee's condition. Our physician reviewer found the requested additional therapy is not 
generally accepted as specific and effective therapy for the patient's condition. The patient has had 
prior therapy for this condition and it appears the patient has not had significant objective functional 
improvements. The appears to be limited by pain and fears ambulation. It does not appear that the patient 
requires the unique skills of a professional therapist to safely and effectively provide treatment, that the 
services can be safely and effectively performed only by a therapist, or for physical therapy and occupational 
therapy, by or under the supervision of a therapist. The patient should be able to transition to a home exercise 
program given the already authorized therapy  and the specialized skill, knowledge and judgment of a qualified 
therapist is not required to establish, design and/or deliver a program to maintain the patient's current condition 
or to prevent or slow further 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 additional physical therapy sessions have not been met. Therefore, we decided 
that the Plan does not have to pre-approve twelve (12) additional physical therapy sessions.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) 
for the enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care, and does not 
require transfer to the LTACH. 
 
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 treated appropriately at the current location, however, there 
was no evidence to suggest the patient would likely require at least 25 additional days of acute care services. 
The enrollee does not require services at the LTACH that are not already available at the current setting. There 
are no services at the LTACH that the enrollee requires that are not already available and covered for the 
patient at the current facility. Therefore, this request for LTACH services will be considered not medically 
necessary at this time. Transfer to a lower level of care may be considered soon once the enrollee no longer 
requires aggressive wound 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve knee surgery with an out of network provider. 
 
You asked the Plan to pre-approve the knee surgery at an out of network facility. You say that you have 
researched the facility and are impressed with their success. The Plan denied your request. The Plan says the 
services are available in 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 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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve knee 
surgery with an out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve negative pressure wound therapy electrical pump, 
stationary or portable (CPT Code E2402), canister, disposable, used with suction pump, each (CPT Code 
A7000) and wound care set, for negative pressure wound therapy electrical pump, includes all supplies and 
accessories (CPT Code A6550). 
 
You asked the Plan to pre-approve the DME. You say that you need wound care supplies because the wound 
has not healed up. The Plan denied your request. The Plan says the Medicare rules have not been met. 
 
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 DME. Our physician reviewer 
found you have a stage 4 pressure ulcer which has been treated with negative pressure for at least five months. 
No measurable degree of healing is documented over the previous month. Wound measurements on September 
11, 2020 (4 cm x 3.8 cm x 4 cm for area of 15.20 cm3) were larger than wound measurements on August 17, 
2020 (4 cm x 2.4 cm x 3 cm for area of 9.6 cm3). The medical records provided do not meet the requirements 
listed in the LCD for Medicare 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 DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve negative pressure wound therapy electrical pump, stationary or portable (CPT Code E2402), 
canister, disposable, used with suction pump, each (CPT Code A7000) and wound care set, for negative 
pressure wound therapy electrical pump, includes all supplies and accessories (CPT Code A6550).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a neuromuscular stimulator for the enrollee. 
 
You asked the Plan to pre-approve the stimulator. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is only considered medically necessary for people who have suffered a severe 
spinal cord injury. 
 
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 the stimulator. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the requested device is experimental in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the stimulator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a neuromuscular stimulator for the enrollee.
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 the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary. 
 
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 based on the documentation provided, the health plan?s denial of LTACH coverage 
should be upheld. The patient is currently undergoing treatment at an ACH following surgery for a ruptured 
cranial arteriovenous malformation (AVM). The patient was intubated/ventilated, but has since been extubated. 
There is no evidence that the patient 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 patient to the LTACH. 
The patient can remain at the current ACH until such time no acute services are required.  The patient can then 
be transferred/discharged to a lower level of care for any ongoing long term care (LTC) 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 LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence garments for the enrollee. 
 
You asked the Plan to pre-approve incontinence supplies. You say that this is medically necessary as the 
enrollee is in a wheelchair. The Plan denied your request. The Plan says these items will be denied as non-
covered, as they are not prosthetic devices, nor are they required for the effective use of a prosthetic device. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence garments for the 
enrollee.