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

 
We decided that the Plan does not have to pre-approve oasis wound matrix, per square (sq) centimeter (cm) 
(Q4102x12) and Grafix prime, GrafixPL prime, Stravix and StravixPL, per sq cm (Q4133x12). 
 
You asked the Plan to pre-approve wound care skin substitute. You say that the enrollee has a diabetic foot 
ulcer on her left lateral foot and has been getting wound care. She is offloading, using special cleansing 
materials, ointments, and dressings. The Plan denied your request. The Plan says the records show that the 
enrollee's wound is healing well with standard wound therapy. Current medical literature indicates that the use 
of more than one skin substitute product at a time for the same wound 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 wound care skin substitute. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found provided records in this case clearly document progressive healing of the 
diabetic foot wound with reduction in wound size from 7.5 cubic centimeters on May 24, 2023, to 0.28 cubic 
centimeters on August 9, 2023, and records do not document arterial studies have been performed to ensure 
adequate arterial blood supply to the foot is present. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of wound care skin substitute have not been met. Therefore, we decided that the 
Plan does not have to pre-approve oasis wound matrix, per square (sq) centimeter (cm) (Q4102x12) and Grafix 
prime, GrafixPL prime, Stravix and StravixPL, per sq cm (Q4133x12).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair, group 2 standard, captain's chair, 
patient weight capacity up to and including 300 pounds (K0823). 
 
You asked the Plan to pre-approve a power wheelchair. You say that instability makes it difficult for the 
enrollee to manipulate a regular wheelchair or walker. The Plan denied your request. The Plan says the request 
is not medically necessary because the records do not tell us why a scooter is not sufficient to meet the 
enrollee's mobility needs. 
 
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 a power wheelchair. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has Parkinson's disease with a shuffling gait and recurrent falls. He is 
reported as too weak to use a manual wheelchair and too unstable for a walker. Per L33789, the enrollee has 
not had a physical therapy evaluation indicating a power wheelchair is 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 power wheelchair have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power wheelchair, group 2 standard, captain's chair, patient weight capacity up to 
and including 300 pounds (K0823).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency generated water vapor thermal therapy. 
 
You asked the Plan to pre-approve radiofrequency generated water vapor thermal therapy. You say that 
radiofrequency generated water vapor thermal therapy is medically necessary. The Plan denied your request. 
The Plan says radiofrequency generated water vapor thermal therapy is considered reasonable and necessary 
when a member has had no previous prostate surgery.  
 
The Plan follows Medicare rules. Medicare rules say that water vapor thermal therapy is covered when the 
criteria listed in the Medicare rules section of this decision are 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 radiofrequency generated water vapor 
thermal therapy. Our reviewer says that the requested radiofrequency generated water vapor thermal therapy is 
not considered medically necessary in this case. Our physician reviewer found the enrollee with benign 
prostatic hyperplasia with lower urinary tract symptoms. The American Urological Association (AUA) score is 
2. Prostate size is 111 cc by magnetic resonance imaging (MRI). Cystoscopy shows trilobar benign prostatic 
hyperplasia (BPH). Maximum flow rate is 4.5 mL/s. Current management is with tadalafil and dutasteride. The 
enrollee was previously treated with Rezum procedure in 2019. The requested water vapor thermal therapy 
does not meet the Medicare LCD coverage criteria.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiofrequency generated water vapor thermal therapy have not been met. 
Therefore, we decided that the Plan does not have to pre-approve radiofrequency generated water vapor 
thermal therapy.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a secondary membranous cataract procedure provided on 
December 05, 2022. 
 
You asked the Plan to pay for a secondary membranous cataract procedure. You say that you believe that the 
provider is in-network. 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 a secondary 
membranous cataract procedure provided on December 05, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neuropsychological testing. 
 
You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your 
request. The Plan says the current information does not support neuropsychological testing, based on a lack of 
findings from a neurobehavioral exam. 
 
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 testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee was diagnosed with cognitive impairment. The enrollee has difficulty with their 
memory. The documentation shows that the enrollee's provider would like to utilize neuropsychological testing 
to modify the enrollee's memory issues. The enrollee had a mini mental status exam, which was 29/30. This 
enrollee does not meet the criteria for psychological and neuropsychological testing as there does not appear to 
be a specific need for the testing which is asked for. Neuropsychological testing is not considered reasonable or medically necessary for the treatment of this enrollees condition utilizing the information provided. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pre-approve neuropsychological testing.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 billed for date of service February 10, 
2023. 
 You asked the Plan to pay for procedure code 99223. The Plan denied your request. The Plan says payment for 
code 99223 is bundled into payment for code 00541. 
 
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, we have confirmed that code 99223 
is a column II code to column I code 00541. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 99223 billed for date of service February 10, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on January 11, 2023. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the records do not 
include a physician order or signed lab requisition. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed. 
 
We looked at the file and Medicare rules. The documentation submitted does not contain a valid physician 
order or lab requisition, or medical records showing the ordering physicians intent that the testing be 
performed. Based on this information, we decided that Medicare rules for coverage of the lab services have not 
been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on January 11, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing, 22 or more drug classes (G0483) 
provided on February 13, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the laboratory service. You say that this test was ordered by a treating physician 
who makes the professional determination of diagnosis and medical necessity to successfully treat their 
patients. 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 definitive drug testing, 22 or more drug classes 
(G0483) provided on February 13, 2023, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable scooter. 
 
You asked the Plan to pre-approve a portable scooter. You say that you need this scooter to get around because 
your quality of life is not good. You also say that you want to be able to go out and do activities like grocery 
shopping, and chores around your home. The Plan denied your request. The Plan says you do not have a 
physician's order for the PMD and you have not been evaluated or had a home assessment. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 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 portable scooter. Our reviewer says 
that a portable scooter is not medically reasonable and necessary. Our physician reviewer found per the medical 
records, you are able to walk 50 yards. Our reviewer also found that the scooter is not necessary to perform 
MRADLs in the home. 
 
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 portable scooter have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a portable scooter.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 27506 rendered on February 20, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that Current Procedural Terminology (CPT) code 27506-AS-LT (1 Unit) remains not supported. 
 
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 27506 is "Open treatment of femoral shaft fracture, with or without external fixation, with insertion of 
intramedullary implant, with or without cerclage and/or locking screws." 
 
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 supported by the medical records. Our reviewer found that the enrollee was being treated for 
displaced intertrochanteric fracture of left femur, initial encounter for closed fracture. The enrollee underwent a 
femoral intramedullary nail insertion hip approach; left intertrochanteric femur fracture fixation with 
intramedullary device on 2/20/23. The procedure in detail cites an open incision was made, length was 
measured, and the nail was placed into position and lightly impacted to be seated appropriately. The opening 
drill bit was used to impact the helical blade into position. The compression feature of the nail was used. The 
anti-rotation screw was tightened and came off one-half turn to allow for controlled compression. The 40mm 
distal interlocking screw was placed. Therefore, the records do support CPT 27506 in this case. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
procedure code 27506 rendered on February 20, 2023.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pneumatic compression device provided on November 28, 
2022. 
 
You asked the Plan to pay for pneumatic compression device. You say that you are requesting reconsideration 
for the services provided. 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 pneumatic compression 
device provided on November 28, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient hospital services provided on February 10, 2022, to 
February 15, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. The Plan denied your 
request. The Plan says that the billed DRG is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with diagnosis code A41.59. We asked our physician 
reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was 
correct in denying the request to pay for the inpatient hospital services at the DRG originally billed. Our 
reviewer says that the use of diagnosis code A41.59 is supported by the records provided. Our physician 
reviewer found that the enrollee had systemic inflammatory response syndrome and culture positive gram-
negative rods, which meets the criteria for diagnosis code A41.59. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for the 
inpatient hospital services provided on February 10, 2022, to February 15, 2022, at the Diagnosis Related 
Group (DRG) originally billed.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the connective tissue disease (CTD) testing provided on July 
27, 2022. 
 
You asked the Plan to pay for the testing. 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 pay for the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that this test uses autoantibody, erythrocyte-bound C4d (EC4d) and B-cell-bound C4d (BC4d) levels to 
aid in diagnoses of systemic lupus erythematosus (SLE), other CTDs and fibromyalgia. We evaluated the 
utility of the this CTD test in predicting SLE disease development and damage progression. Per the literature, 
Future studies will evaluate the utility of AVISE in predicting longitudinal disease activity and flares. These 
results will determine whether this test's positivity can predict disease activity at shorter intervals. The 
requested testing at issue in this case was 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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the connective tissue disease (CTD) testing provided on July 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant Reveal molecular diagnostic test (81479) provided 
February 16, 2023. 
 
You asked the Plan to pay for the laboratory test. You say that please note that you provide the Guardant 
Reveal molecular diagnostic test at the request of the ordering physician. The Plan denied your request. The 
Plan says Guardant Reveal is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules.  Per DEX Diagnostics, Guardant Reveal is not covered by Medicare. Per NCCN (National Comprehensive Cancer Network) Guidelines for Colon Cancer, Version 2.2023, there is 
insufficient data to recommend post-surgical ctDNA (circulating tumor deoxyribonucleic acid) to estimate risk 
of recurrence or determine adjuvant therapy. Based on this information, we decided that Medicare rules for 
coverage of the laboratory service have not been met. Therefore, we decided that the Plan does not have to pay 
for Guardant Reveal molecular diagnostic test (81479) provided February 16, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve additional PT visits. You say that you have been improving with PT and 
wish for the services to continue. The Plan denied your request. The Plan says additional PT 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 PT visits. 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 additional requested therapy is not generally accepted as specific 
and effective therapy for your condition beyond what was approved by the health plan. The records do not 
demonstrate that the unique skills of a professional therapist are required to safely and effectively provide 
treatment, that the services can be safely and effectively performed only by a therapist, or by or under the 
supervision of a therapist. The requested services are not part of a maintenance program, and the specialized 
skill, knowledge and judgment of a qualified therapist is not required to establish, design or deliver a program 
to maintain your current condition or to prevent or slow further deterioration. You have had instruction in a 
home exercise program and your functional level does not require ongoing formal therapy. The requested 
additional therapy sessions are 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 additional PT visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve additional physical therapy (PT) visits.