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

 
We decided that the Plan does not have to pre-approve an application of skin substitute graft to trunk, arms, 
legs (15271) and Kerecis omega3, per square centimeter (Q4158). 
 
You asked the Plan to pre-approve biological skin substitute. You say that you are appealing the medical 
necessity denial for a biological skin substitute because of an unspecified open wound of the buttock, initial 
encounter, pressure ulcer of sacral region, stage 3, and rheumatoid arthritis without rheumatoid factor. The Plan 
denied your request. The Plan says the details received from the provider do not meet Medicare guidelines that 
show a medical reason the enrollee needs a biological skin substitute. 
 
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 biological 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 notes describe the enrollee with improving wounds between July and 
September dates with the above treatment according to the provided documentation. Therefore, without failure 
of the above treatment defined as no improvement or worsening, grafting is not justified as the enrollee does 
not meet criteria. Therefore, the Kerecis Omega3 will be considered not medically necessary 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 biological skin substitute have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an application of skin substitute graft to trunk, arms, legs (15271) and 
Kerecis omega3, per square centimeter (Q4158).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve N-Plate. 
 
You asked the Plan to pre-approve N-Plate. You say that the services are necessary. The Plan denied your 
request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been 
met. 
 
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 N-Plate. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found N-Plate is indicated for the treatment of Immune thrombocytopenic purpura (ITP) and to 
increase survival in adults and in pediatric patients (including term neonates) acutely exposed to 
myelosuppressive doses of radiation (Hematopoietic Syndrome of Acute Radiation Syndrome [HSARS]. Thrombocytopenia and clinical condition increase the risk for bleeding. The review has determined that the 
requested N-Plate 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 N-Plate have not been met. Therefore, we decided that the Plan does not have to 
pre-approve N-Plate.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (88305) provided on May 23, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. 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 items/services at issue were 
reimbursed by the Plan under claim number NTL7979946100. Comparison of the two claims shows these are 
exact duplicates. There is no evidence presented to support that the billed items/services were provided twice 
on the same date. Based on this information, we decided that the Medicare rules for the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (88305) provided on May 
23, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endoscopy, wrist, surgical, with release of transverse 
carpal ligament (29848). 
 
You asked the Plan to pre-approve endoscopy, wrist, surgical, with release of transverse carpal ligament. You 
say that this is medically necessary. The Plan denied your request. The Plan says the records do not show that 
the enrollee has been treated with nonoperative treatment such as a 4-week trial of splinting or local 
corticosteroid injection. 
 
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 endoscopy, wrist, surgical, with release 
of transverse carpal ligament. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found detailed documentation regarding a trial 
and failure of recent, reasonable, comprehensive, less invasive conservative care measures is not evident. 
Additionally, diagnostic testing was not provided to corroborate the pathology. There are limited large-scale, 
long-term references showing the safety and efficacy of the requested surgery in this clinical setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of endoscopy, wrist, surgical, with release of transverse carpal ligament have not 
been met. Therefore, we decided that the Plan does not have to pre-approve endoscopy, wrist, surgical, with 
release of transverse carpal ligament (29848).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids provided on May 25, 2023. 
 
You asked the Plan to pay for the hearing aids. You say that the in-network provider's office location is too 
inconvenient for you. You say you are 85 years old, and the office is in a high traffic area near a high school 
intersection. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only received by the network provider.  
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aids have not been met. Specifically, the hearing aids were received by an out-of-
network provider. Therefore, we decided that the Plan does not have to pay for the hearing aids provided on 
May 25, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compressor and the pneumatic appliance to 
be provided by an OON provider.  
 
You asked the Plan to pre-approve a pneumatic compressor and the pneumatic appliance. You say that you are 
requesting reconsideration of the denied items. The Plan denied your request. The Plan says the items were not 
approved. 
 
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 Plan contract 
says the enrollees POS benefit only applies to covered routine dental services. The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a pneumatic compressor and the pneumatic appliance to be provided by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid (DNA or 
RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), 
amplified probe technique (87635) provided on May 31, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the laboratory testing. You say that as a clinical laboratory, you do not directly 
see patients and are at the will of providers and clinics to verify network status upon ordering the tests in 
question. 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 infectious agent detection by nucleic acid 
(DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease 
[COVID-19]), amplified probe technique (87635) provided on May 31, 2023, by an out-of-network (OON) 
provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on May 28, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you were 
stung by a scorpion, used the EpiPen but nothing got better so you took Benadryl and called the ambulance 
who checked your vitals. You also say that it wasn't necessary at the time to be transported since you were 
made stable by the emergency medical technician. The Plan denied your request. The Plan says these services 
are not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on May 28, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on May 28, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergent ambulance transport received on May 24, 
2023. 
 
You asked the Plan to pay for the non-emergent ambulance transport. You say that the services were medically 
necessary so that you could make it to your doctors appointment. The Plan denied your request. The Plan says 
the non-emergent transportation service locations are not covered. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when 
they meet certain origin and destination requirements. A doctors office is not a covered destination.  
 
The services you have asked the Plan to pay for are ambulance transport services to a doctors office. 
Therefore, we decided that the Plan does not have to pay for the non-emergent ambulance transport received on 
May 24, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient rehabilitation facility (IRF) admission and 
services provided from MARCH 07, 2023, through MARCH 13, 2023. 
 
You asked the Plan to pay for the IRF care. You say that the enrollee required rehabilitation in order to 
maintain sobriety. The Plan denied your request. The Plan says the stay at the inpatient rehabilitation facility 
was 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 in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the 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 enrollee was not showing any withdrawals and had normal vital signs. It did not 
appear medically necessary and reasonable to have psychiatric/detoxification care provided at the acute 
inpatient level of care rather than a lower level of care as they did not have dangerousness to self or others, 
perceptual disturbance including delusions, or auditory or visual hallucinations. The health plans denial of 
inpatient psychiatric/detoxification services appears appropriate. 
 
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 pay for the acute inpatient rehabilitation facility (IRF) admission and services provided from MARCH 07, 
2023, through MARCH 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prefabricated abutment (D6056) and abutment 
supported porcelain fused to metal crown (D6059). 
 
You asked the Plan to pre-approve prefabricated abutment and abutment supported porcelain fused to metal 
crown . You say that this is medically necessary. The Plan denied your request. The Plan says this is not a 
covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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 
prefabricated abutment (D6056) and abutment supported porcelain fused to metal crown (D6059).
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve tissue expander placement in breast reconstruction, including 
subsequent expansion (19357). 
 
You asked the Plan to pre-approve expander placement. You say that the device/procedure is medically 
necessary. The Plan denied your request. The Plan says that Medicare guidance is not available for gender 
affirming interventions. The request for a bilateral breast expander placement to reverse prior mastectomy for 
gender dysphoria is considered not medically necessary. 
 
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 expander placement. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found code 19357 is on the Medicare Advantage preauthorization list for policy M- SUR40, 
Reconstructive Breast Surgery, Mastopexy, and Management of Breast Implants. This policy has Medicare 
guidance for breast reconstruction procedures performed to reshape the breast when unrelated to breast cancer, 
as well as the removal of breast implants: Plastic Surgery (L37020). However, this LCD specifically states that 
it "does not address coverage for procedures associated with transgender surgery. All coverage determinations 
for transgender surgery are currently handled by individual consideration on a case-by-case review with 
particular consideration of the World Professional Association for Transgender Health (WPATH) Standards of 
Care and interpreted through the various Medicare statutes, rules, regulations, and manual instructions. In this 
case, you currently wear 3 breast binders to go out in public. You still feel that this does not help you to pass as 
male. You have been seeing Layne Prest at Peace Health Family Health Center in Vancouver for therapy who 
has written a letter of support for you to pursue top surgery. The review has determined that the items/services 
at issue in this case are medically reasonable and necessary. You meet criteria for the requested procedure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of expander placement have been met. Therefore, we decided that the Plan has to 
pre-approve tissue expander placement in breast reconstruction, including subsequent expansion (19357).  
 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: Favorable

 
We decided that the Plan has to pre-approve an electronic connection (E2311). 
 
You asked the Plan to pre-approve an electronic connection. You say that when two power seating 
functions/actuators/motors are provided, one unit of E2311 is allowed. The Plan denied your request. The Plan 
says that although there are three approved power options on this wheelchair (tilt and elevating leg rests), there 
is not a medical need to control these power options through the joystick. 
 
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 an electronic connection. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found the patient is non-ambulatory and requires a power wheelchair for mobility and 
performing daily activities. They cannot perform pressure relief independently due to upper extremity 
weakness and require a power wheelchair with power tilt for adequate pressure relief and positioning. Our 
reviewer found that the patient is noted to have a history of skin breakdown. Power elevating leg rests are 
required for positioning of the lower extremities. The complexity of the patients seating and positioning needs 
necessitates a more complex group 3 power wheelchair base. Our physician reviewer also found that the 
electronic connection is necessary to operate the group 3 power wheelchair base and the power options via a 
joystick. It is required to operate the power options on a group 3 power wheelchair. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an electronic connection have been met. Therefore, we decided that the Plan has 
to pre-approve an electronic connection (E2311).  
 
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  the pneumatic compression device (E0675) and accessories. 
 
You asked the Plan to pay for  the pneumatic compression device. You say that the item was medically 
necessary. The Plan denied your request. The Plan says a PCD is not covered for preventative services. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for  the pneumatic compression device (E0675) and accessories.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve laminectomy, facetectomy, and foraminotomy at L1-L2 
and L2-L3. 
 
You asked the Plan to pre-approve laminectomy, facetectomy, and foraminotomy at L1-L2 and L2-L3. You say 
that you disagree with the Plan's denial. The Plan denied your request. The Plan says the requested services are 
not covered unless enrolled in a clinical study. 
 
The Plan must follow Medicare rules. Medicare rules say that percutaneous image-guided lumbar 
decompression (PILD) will be covered by Medicare when provided in a clinical study through Coverage with 
Evidence Development (CED) for beneficiaries with lumbar spinal stenosis (LSS) who are enrolled in an 
approved clinical study. 
 
We looked at the file and Medicare rules. Review of the file does not support that the enrollee was enrolled in a 
clinical study. Based on this information, we decided that Medicare rules for coverage of laminectomy, 
facetectomy, and foraminotomy at L1-L2 and L2-L3 have not been met. Therefore, we decided that the Plan 
does not have to pre-approve laminectomy, facetectomy, and foraminotomy at L1-L2 and L2-L3.