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

 
We decided that the Plan does not have to pre-approve PuraPly antimicrobial wound matrix. 
 
You asked the Plan to pre-approve PuraPly antimicrobial wound matrix. You say that PuraPly 
antimicrobial wound matrix is medically necessary. The Plan denied your request. The Plan says PuraPly 
antimicrobial wound matrix is not medically necessary and does not meet the Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules. 
 
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 PuraPly antimicrobial wound matrix. 
Our reviewer says that PuraPly antimicrobial wound matrix is not medically necessary. Our physician 
reviewer found that the enrollee is a 62-year-old who has a pressure ulcer of the left hip, stage 4. The Medicare 
LCD coverage criteria is not met based on the provided documentation. The wound appears to have significant 
granulation tissue and is healing without the use of a Matrix product, suggesting a positive response to the 
current more conservative treatment. Also, the use of Matrix appears to not be feasible for this enrollee as he is 
likely to remove or manipulate it.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PuraPly antimicrobial wound matrix have not been met. Therefore, we 
decided that the Plan does not have to pre-approve PuraPly antimicrobial wound matrix.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on July 11, 2022, billed with 
codes 81292 and 81321. 
 
You asked the Plan to pay for the testing services. You say that the treatment sought was medically necessary. 
The Plan denied your request. The Plan says panel testing should be billed using one CPT code. The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the testing services have 
not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on July 
11, 2022, billed with codes 81292 and 81321.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve the proton beam therapy (PBT) (77014, 77387, 77470, 77522, 
77523, 77525, G6002). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says that the requested services are not covered by Medicare or the Health Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found proton therapy is not an accepted standard for routine radiation for rectal cancers; with 
exceptional circumstances (such as prior irradiation or unusual anatomy) it can be considered medically 
necessary. For this enrollee, there is a plan comparison showing an appreciable benefit. Our physician 
reviewers decision is therefore favorable as while routine treatment with proton therapy for rectal cancer 
would not be furnished in accordance with accepted standards of care, in exceptional cases proton therapy can 
be considered medically necessary. For this enrollee, the reduction in small bowel exposure is plausible, and 
clinically meaningful such that proton therapy would be within 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 been met. Therefore, we decided that the Plan has to pre-
approve the proton beam therapy (PBT) (77014, 77387, 77470, 77522, 77523, 77525, G6002).  
 
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 a left total knee replacement (27447). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the records sent in by the provider show the enrollee meets all these 
requirements with the exception for optimal medical management including completion of a 6-week course of 
supervised physical therapy. 
 
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 the detailed documentation is not evident regarding a trial and failure of recent, reasonable, 
comprehensive less invasive conservative care measures. The enrollee has only had three (3) sessions of physical therapy. There are no other conservative measures noted to have been tried. There are limited large-
scale, long-term references showing the safety and efficacy of the requested surgery in this clinical setting. No 
compelling rationale is presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Therefore, the requested left total knee replacement (27447), 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a left total knee replacement (27447).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for air ambulance transportation provided from the region of 
Guadeloupe, France to the United States of America on March 9, 2022. 
 
You asked the Plan to pay for air ambulance. You say that this was a life and death situation that needed to be 
treated as soon as possible. The Plan denied your request. The Plan says transportation to the United States 
from another country is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services furnished outside of the 
United States are only covered under limited, specified circumstances. The Plan has a worldwide coverage 
benefit that goes beyond Medicares coverage. For that reason, the Plans rules apply. The Plan covers 
emergency care, urgently needed care, and emergency ambulance transportation from the scene of an 
emergency the nearest medical treatment facility. Transportation back to the United States from another 
country is not covered. 
 
We looked at the file and Medicare rules. This service does not fall within Medicares coverage for out-of-
country services. Additionally, this service is not covered by the Plan because transportation back to the United 
States from another country is explicitly excluded from coverage. Therefore, we decided that the Plan does not 
have to pay for air ambulance transportation provided from the region of Guadeloupe, France to the United 
States of America on March 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound therapy (97035), therapeutic excersizes 
(97110), and electrical stimulation (G0283) provided on October 18, 2022. 
 
You asked the Plan to pay for the ultrasound therapy (97035), therapeutic excersizes (97110), and electrical 
stimulation (G0283). You say that the services should be covered. The Plan denied your request. The Plan says 
that unauthorized, out-of-network care is not covered. 
 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the ultrasound therapy 
(97035), therapeutic excersizes (97110), and electrical stimulation (G0283) provided on October 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the opioid treatment program (OTP) services provided on 
December 5, 2022. 
 
You asked the Plan to pay for the OTP services. The Plan denied your request. The Plan says this provider is 
not payable for these services. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare Part B coverage is available for 
outpatient Opioid Treatment Program services provided by hospitals, CAHs, and Free-Standing Opioid 
Treatment Program facilities.  
 
We looked at the file and Medicare rules. The billing provider is eligible for payment for OTP services. 
Individual providers are not payable for OTP services. Based on this information, we decided that Medicare 
rules for coverage of the OTP services have not been met. Therefore, we decided that the Plan does not have to 
pay for the opioid treatment program (OTP) services provided on December 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service October 30, 
2022. 
 
You asked the Plan to pay for procedure code 99053. The Plan denied your request. The Plan says procedure 
code 99053 is considered bundled and not separately payable. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99053 billed for date of service October 30, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous injection of allogenic cellular and/or 
tissue-based product, intervertebral disc, unilateral or bilateral injection, with fluoroscopic guidance, lumbar; 
first level (CPT 0627T). 
 
You asked the Plan to pre-approve the outpatient. You say that you are appealing the denied decision of the 
preservice review for the ViaDisc Np, Current Procedural Terminology (CPT) code 0627T. The Plan denied 
your request. The Plan says the treatment is not medically necessary, there are other accepted standards of care 
that can be used. This is considered to be 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 outpatient. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is limited published, large-scale, long-term peer-reviewed literature that shows this 
request to be an effective and/or safe treatment for the noted pathology. Further studies are needed to 
demonstrate this request has beneficial outcomes compared with conventional treatment. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Therefore, the requested percutaneous injection of allogenic cellular and/or tissue-
based product, intervertebral disc, unilateral or bilateral injection with fluoroscopic guidance, lumbar, first level 
(CPT 0627T) ViaDisc, 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 outpatient have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous injection of allogenic cellular and/or tissue-based product, intervertebral 
disc, unilateral or bilateral injection, with fluoroscopic guidance, lumbar; first level (CPT 0627T).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a microprocessor knee (L5848, L5845, L5828, L5856, L5925). 
 
You asked the Plan to pre-approve a microprocessor knee. You say that a microprocessor knee is medically 
necessary for the enrollee. The Plan denied your request. The Plan says that the requested microprocessor knee 
exceeds the enrollee's medical needs. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a microprocessor knee. Our reviewer 
says that the requested microprocessor knee is medically necessary. Our physician reviewer found the reviewer 
found that there is some evidence that a microprocessor knee reduces fall risk. The reviewer found that the 
enrollee has adjusted to and relied upon a microprocessor knee previously. The reviewer found that adjustment 
to a lower functioning prosthesis places the enrollee at increased risk of fall and injury. Therefore, the reviewer 
found that a microprocessor knee is medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a microprocessor knee have been met. Therefore, we decided that the Plan has 
to pre-approve a microprocessor knee (L5848, L5845, L5828, L5856, L5925).  
 
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 the Vertiflex Superion interspinous spacer system 
(22869, 22870). 
 
You asked the Plan to pre-approve the Vertiflex procedure.. You say that the enrollee would benefit from this 
procedure and is scheduled April 6, 2023. The Plan denied your request. The Plan says the requested procedure 
is still being investigated as there is limited evidence available to show the effectiveness of this procedure. 
 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 Vertiflex procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Vertiflex device is experimental for back pain. 
 
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 Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex Superion interspinous spacer system (22869, 22870).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fundus photography with interpretation and report 
(92250) provided on December 12, 2022. 
 
You asked the Plan to pay for the fundus photography. You say that you had double cataract surgery in both 
eyes, and your vision had changed, so you had the eye exam to get new glasses. You also say that you feel this 
service should be paid. The Plan denied your request. The Plan says as this claim was billed with diagnosis 
codes H52.03 (Hypermetropia, bilateral) and Z96.1 (Presence of intraocular lens), there is no coverage for this 
intraocular photography service. 
 
The Plan must follow Medicare rules. Medicare rules say that payment can be made for the use of this 
procedure by an ophthalmologist in the situations listed in the Medicare rules section of this letter when it is 
reasonable and necessary for the individual patient to receive these services. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the fundus photography have not been met. Therefore, we decided that the Plan does not have to 
pay for the fundus photography with interpretation and report (92250) provided on December 12, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have pre-approve a PET scan of the brain. 
 
You asked the Plan pre-approve a PET scan of the brain. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 pre-approve the PET scan. Our physician reviewer 
found the service is not 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 the PET scan have not been met. Therefore, we decided that the Plan does not 
have pre-approve a PET scan of the brain.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 7, 2022, billed with 
codes 81314 and 81345. 
 
You asked the Plan to pay for the testing billed. You say that the treatment sought was medically necessary. 
The Plan denied your request. The Plan says panel testing should be billed using one CPT code. 

The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This panel testing was not billed with a single panel code as required. 
Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pay for the genetic testing provided on October 7, 2022, billed with 
codes 81314 and 81345.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group three power wheelchair (PWC) with multiple 
power options (K0861), expandable controller (E2377), harness (E2313), electronic connection (E2311), and 
other related accessories.  

You asked the Plan to pre-approve the PWC and accessories. You say that the items are medically necessary. 
The Plan denied your request. The Plan says the items are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a group 3 PWC with multiple power options is 
considered medically necessary when criteria listed in Medicare Rules section is 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 PWC and accessories. Our reviewer 
says that the items are not medically necessary. Our physician reviewer found the enrollee is not at high risk for 
skin breakdown, does not use intermittent catheterization and does not have spasticity. He has adequate upper 
extremity strength to manage individual controls and does not require an expandable controller. Since, the 
PWC base is not medically necessary, all accessories are considered not 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 the PWC and accessories have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a group three power wheelchair (PWC) with multiple power options 
(K0861), expandable controller (E2377), harness (E2313), electronic connection (E2311), and other related 
accessories.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 25, 2022, billed with 
codes 81314, 81345, and 81272. 
 
You asked the Plan to pay for the genetic testing billed. You say that the treatment sought was medically 
necessary. The Plan denied your request. The Plan says panel testing should be billed using one CPT code. 

The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing have 
not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
October 25, 2022, billed with codes 81314, 81345, and 81272.