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

 
We decided that the Plan does not have to pre-approve intensity-modulated radiation therapy (IMRT). 
 
You asked the Plan to pre-approve IMRT. You say that you would like to protect organs at-risk and adjacent 
structures. The Plan denied your request. The Plan says this 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 IMRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found IMRT is not experimental, but rather a useful tool available to radiation oncologists to 
potentially reduce toxicity and improve the dose distribution in patients when the dose-volume exposure of 
normal tissues warrant its use. The American Society for Radiation Oncology's (ASTRO's) position is that 
IMRT is necessary when the need is sufficiently supported, which is important when used for non-standard 
indications such as palliative radiotherapy. Wihtout justification for the need of IMRT this would not be 
furnished in accordance with accepted standards of medical practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IMRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve intensity-modulated radiation therapy (IMRT).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Inlyta. 
 
You asked the Plan to pre-approve Inlyta. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
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. Therefore, we decided that the Plan does not have to pre-approve Inlyta.  
 
Benefits for Inlyta may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assistant surgeon services provided on May 16, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says assistant surgeon 
services are not payable for this procedure. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) code 27502. The Medicare Fee Schedule Database contains a surgical indicator 
of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically 
necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the 
services have not been met. Therefore, we decided that the Plan does not have to pay for the assistant surgeon 
services provided on May 16, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from June 1, 2021, to June 6, 2021. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says the provider has reported skilled services with the incorrect PDPM Health Insurance 
Prospective Payment System (HIPPS) Score. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report SNF services with the correct PDPM score. 
 
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 there is insufficient clinical 
documentation supporting isolation for infectious disease in this case for the SNF services provided from June 
1, 2021, to June 6, 2021. The case file contains documentation of Covid-19 Resident Monitoring for this 
enrollee from 6/1/21 through 6/6/21. The enrollee was working with therapy. On 6/2/21, the enrollee expressed 
satisfaction with her new room and roommate. On 6/3/21, the enrollee went to the hospital for a blood 
transfusion. 
 
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 skilled nursing facility (SNF) services provided to the enrollee from June 1, 2021, to June 6, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiation treatment (Brachytherapy) (77290, 77280). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says there is no clinical support for using this type of radiation therapy to treat the enrollee's 
skin cancer (considered investigational). 
 
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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found their decision in this case is unfavorable due to lack of demonstration of need for stereotactic 
radiation therapy (SRT) vs. traditional external beam radiation, and statements from National Comprehensive 
Cancer Network (NCCN) guidelines and medical societies that question its use. It would therefore not be 
considered to be furnished in accordance with accepted standards 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve radiation treatment (Brachytherapy) (77290, 77280).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on April 25, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this claim is a 
duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the services at issue were reimbursed 
by the Plan on July 27, 2022. Comparison of the two claims shows these are exact duplicates. There is no 
evidence presented to support that the billed services were provided twice on the same date. Based on this 
information, we decided that the Medicare rules for the services have not been met. Therefore, we decided that 
the Plan does not have to pay for the services provided on April 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 genetic testing, provided on May 4, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the genetic testing. You say that Guardant360 was ordered by an in-network 
provider to assist determining the optimal treatment options for the enrollee. The Plan denied your request. The 
Plan says enrollees must receive their medical services from an in-network provider with the exception being 
urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization 
before services being rendered. 
 
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 items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the Guardant360 genetic testing, provided on May 
4, 2022, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve personal care assistant services (CPT code T1019). 
 
You asked the Plan to pre-approve the services. You say that The Plan contract says that custodial care is 
personal care that does not require the continuing attention of trained medical or paramedical personnel, such 
as care that helps you with activities of daily living, such as bathing or dressing and is not covered under any 
condition. Homemaker services include basic household assistance, including light housekeeping or light meal 
preparation and is not covered under any condition. You can find this information in Chapter 4 on pages 99-
100 of the Plan's 2022 Evidence of Coverage. The Plan denied your request. The Plan says Medicare does not 
cover personal care assistant services; this service may be covered under the enrollee's Medicaid benefit. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Specifically, we find that the services at issue in this case are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve personal care 
assistant services (CPT code T1019).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus Tumor Origin Test provided on April 27, 2022. 
 
You asked the Plan to pay for the Tempus Tumor Origin Test. You say that this claim should be reprocessed. 
The Plan denied your request. The Plan says other than the pathology report, there were no medical records 
included with this appeal. The records do not show why the provider ordered this specific gene test, why the 
provider ordered the number/type of genes tested, or what impact this will have on the enrollee's clinical 
course. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the Tempus Tumor Origin Test have 
been met. The Plan requested legible medical records for review. These records were not received. Therefore, 
we decided that the Plan does not have to pay for the Tempus Tumor Origin Test provided on April 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the ventilator is necessary. The Plan 
denied your request. The Plan says the request is not medically necessary because the enrollee's records show 
that the requested device is to be used in a bilevel positive airway pressure (BiPAP) mode average volume-
assured pressure support (AVAPS)-AE), which can be provided by another device. 
 
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 home ventilator. Our physician 
reviewer found claims for ventilators used to provide CPAP or bi-level continuous positive airway pressure 
(CPAP) therapy for conditions described in this RAD policy will be denied as not 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 the home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (CPT code E0466).
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) and wound care set, for negative pressure wound therapy electrical 
pump, includes all supplies and accessories (A6550). 
 
You asked the Plan to pre-approve the DME. You say that the provider has been using the negative pressure 
wound vac for the enrollee's venous ulcer at their facility to treat the enrollee on an outpatient basis. The Plan 
denied your request. The Plan says the enrollee's request is not medically necessary because their records show 
the enrollee has already had four (4) months of wound VAC therapy (and those services were approved by the 
Plan). 
 
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 the request is not medically necessary because the records show the enrollee already had four (4) months 
of wound VAC therapy. The review has determined that 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) and 
wound care set, for negative pressure wound therapy electrical pump, includes all supplies and accessories 
(A6550).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intracept procedure (64628). 
 
You asked the Plan to pre-approve the intracept procedure. You say that the surgery is necessary. The Plan 
denied your request. The Plan says the service is considered experimental and investigational. 
 
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 intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found documentation was/is lacking regarding reasonably detailed and/or evidenced 
findings supportive of the spinal vertebral bodies as being the overwhelming primary generators of the 
enrollees chronic persistent pain. Documentation does not support actual formal surgical ablation of pre-
designated basivertebral nerves as being medically necessary and/or reasonable at this time. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Therefore, the requested intracept intraosseous basivertebral nerve ablation at L4 and 
L5, in this case, is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the intracept procedure (64628).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy visit (90832) provided on April 5, 2022. 
 
You asked the Plan to pay for the psychotherapy service. You say that this service should be covered. The Plan 
denied your request. The Plan says there was no documented contact with the attending or primary care 
physician. 
 The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the psychotherapy service have not been met. Specifically, the record does not include 
documentation of a consultation or an attempt to consult the enrollee's primary/attending physician as required 
by Medicare rules. Therefore, we decided that the Plan does not have to pay for the psychotherapy visit 
(90832) provided on April 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 36522 provided on June 8, 2022 to June 9, 
2022. 
 
You asked the Plan to pay for procedure code 36522. You say that this service was medically necessary and 
billed correctly. The Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
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 CPT code 36522 is not supported in the medical record. Specifically, the claim was billed without 
a required Q0 modifier. Based on this information, we decided that Medicare rules for coverage of procedure 
code 36522 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
36522 provided on June 8, 2022 to June 9, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued care with the out-of-network (OON) 
podiatrist. 
 
You asked the Plan to pre-approve continued care with the OON podiatrist. You say that continued care with 
the OON podiatrist is medically necessary. The Plan denied your request. The Plan says continued care with 
the OON podiatrist is not medically necessary. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 continued care with the OON podiatrist. 
Our reviewer says that continued care with the OON podiatrist is not medically necessary. Our physician 
reviewer found the enrollee has a diagnosis of Unspecified fracture of right foot, subsequent encounter for 
fracture with delayed healing. The enrollee has hammertoe and bunion deformities. The available clinical 
documentation in the case file does not support that the enrollee in this case is currently receiving active 
treatment and/or medical management of her condition that makes it medically necessary for the enrollee to 
continue care with the out-of-network podiatry provider as requested. The clinical documentation does not 
identify anything unique about this enrollee's condition that would make it medically necessary for her to 
continue care with the OON podiatrist. The Plan has shown that they have in-network podiatry specialists who 
have the qualifications and expertise necessary to meet the current medical Standards of Care required for 
treatment of the enrollee's condition. The enrollee's medical management and/or follow-up care can be safely 
transitioned to an in-network podiatry specialist 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 continued care with the OON podiatrist have not been met. Therefore, we 
decided that the Plan does not have to pre-approve continued care with the out-of-network (OON) podiatrist.
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 enrollee is too medically complex for 
a lower level of care due to extensive wound care they require and the inability to participate three hours of 
therapy per day. You say that the enrollee also needs therapy to return to the least restrictive and most 
independent environment possible. The Plan denied your request. The Plan says an LTACH admission is not 
medically necessary, and the enrollee can safely receive the care they need in another setting. 
 
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 has ongoing medical issues and still requires acute care services 
before transitioning to a lower level of care. 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. They are 
continuing to receive acute care services, and these have not been denied.  
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.