Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aviva plus test strips. 
 You asked the Plan to pre-approve Aviva plus test strips. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says only the preferred brand products listed in the EOC are covered.  
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for test strips. Therefore, we decided that the Plan does not have to pre-approve Aviva plus test strips.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMs device (33289). 
 
You asked the Plan to pre-approve a CardioMEMs device. You say that this device is medically necessary for 
worsening heart failure. The Plan denied your request. The Plan says the clinical value and effectiveness of the 
CardioMEMs device has not been demonstrated in the peer-reviewed literature. 
 
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 CardioMEMs device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there remains a dearth of randomized, blinded clinical studies examining long-
term clinical outcomes establishing the value of CardioMEMS in patient management. As a result, at this time 
the CardioMEMS system would not be considered medically appropriate and necessary in this enrollee's clinical management. 
 
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 CardioMEMs device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMs device (33289).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete denture - maxillary (D5110), and mandibular 
partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests 
and teeth) (D5214) provided on June 14, 2022. 
 
You asked the Plan to pay for the complete denture - maxillary and mandibular partial denture. You say that 
you are asking for the claim to be reconsidered and paid. The Plan denied your request. The Plan says these 
services are not covered under your dental benefits. 
 
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 pay for the 
complete denture - maxillary (D5110), and mandibular partial denture - cast metal framework with resin 
denture bases (including retentive/clasping materials, rests and teeth) (D5214) provided on June 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Minuteman procedure (22840, 22612). 
 
You asked the Plan to pre-approve a Minuteman procedure. 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 a Minuteman procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found no compelling rationale is presented or extenuating circumstances noted to support 
the medical necessity of this request as an exception. Therefore, the requested Minuteman device at L4-5 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 a Minuteman procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Minuteman procedure (22840, 22612).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospice or home health care services provided by an out-
of-network provider on March 1, 2021. 
 
You asked the Plan to pay for the hospice or home health care services. You say that the claim has been 
submitted before and it should not be denying for timely reasons. The Plan denied your request. The Plan says 
the corrected claim was not filed within 1 year of the dat of service. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
  The record shows that a claim for the hospice or home health care services was not filed until April 4, 2023. 
This means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for the hospice or home health care services provided 
by an out-of-network provider on March 1, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance without transport services received on 
January 19, 2023. 
 
You asked the Plan to pay for the ambulance without transport services. You say that you were unaware that if 
you are not transported to the hospital then you would have to pay out of pocket for the expenses.  The Plan 
denied your request. The Plan says without transport there is no billable service. 
 
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 January 19, 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 without transport services received 
on January 19, 2023.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for the non-emergency transportation services provided on June 13, 2023. 
 
You asked the Plan to pay for the non-emergency transportation services. You say that the services were 
medically necessary. The Plan denied your request. The Plan says that the transport was not medically 
necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same 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 pay for the non-emergency transportation services. 
Our reviewer says that the transport services were medically necessary. Our physician reviewer found the 
documentation supports that other means of transport were contraindicated for this enrollee. The enrollee 
required the expertise and services that only a fully equipped ambulance can provide for safe transport. 
Documentation supports that the ambulance transport on June 13, 2023, was medically reasonable and 
necessary for the enrollee. 
 
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 non-emergency transportation services have been met. Therefore, we 
decided that the Plan has to pay for the non-emergency transportation services provided on June 13, 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 pre-approve a home ventilator system. 
 
You asked the Plan to pre-approve a home ventilator system. The Plan denied your request. The Plan says a 
home ventilator is not medically necessary for this patient because their needs can be met with an alternative 
device such as a BiPAP device with average volume-assured pressure support (AVAPS).  
 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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 home ventilator system. Our reviewer 
says that a home ventilator system is not medically necessary. Our physician reviewer found that the enrollee 
has COPD and chronic respiratory failure. However, there is no documented failure or inability to tolerate a 
BiPAP or BiPAP with AVAPS. Therefore, the enrollee does not meet the best standard practice at this time for 
a home ventilator. 
 
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 home ventilator system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a home ventilator system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve diabetic test strips (200 per 30 days) to be provided by a 
non-preferred brand. 
 
You asked the Plan to pre-approve diabetic test strips. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the requested non-preferred and amount of test strips is not medically 
necessary. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced in the Medicare rules section. The rules 
also say that plans may specify brands and manufacturers as preferred and charge lower cost-sharing for the 
preferred brands or may limit the DME to only those preferred brands and manufacturers. Plans must ensure 
that enrollees have access to all medically necessary (including non- preferred) DME products or brands. The 
rules also say that a health plan must disclose to its enrollees, in clear accurate terms, the benefits offered under 
a plan, including applicable conditions and limitations associated with receipt or use of benefits. 
 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 diabetic test strips. Our reviewer says 
that the documentation does not support the need for the additional diabetic testing strips. Our physician 
reviewer found the enrollee has diabetes and is not on insulin. The record provided is insufficient to establish 
the medical necessity and reasonableness, as defined by Medicare rules, of the requested items. Therefore, the 
enrollee does not meet criteria for the requested amount of test strips. 
 
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 specific requested diabetic test strips have not been met. Therefore, we 
decided that the Plan does not have to pre-approve diabetic test strips (200 per 30 days) to be provided by a 
non-preferred brand.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a new patient home visit, and advance care planning services 
provided on May 08, 2023. 
 
You asked the Plan to pay for a new patient home visit, and advance care planning services. You say that these 
services were medically necessary. 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 new patient home 
visit, and advance care planning services provided on May 08, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy (PT) services to be provided by an out-
of-network (OON) provider.  
 
You asked the Plan to pre-approve the PT services. You say that the services are medically necessary due to the 
wait times to get into a network provider. The Plan denied your request. The Plan says the services are not 
medically necessary. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the 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 
physical therapy (PT) services to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve low frequency, non-contact, non-thermal ultrasound to 
be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve low frequency, non-contact, non-thermal ultrasound to be provided by an 
OON provider. You say that the services are necessary. The Plan denied your request. The Plan says there are 
in-network providers that are able to provide these services. Therefore, coverage criteria have not been met. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the 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 
low frequency, non-contact, non-thermal ultrasound to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve F2 gene analysis and F5 gene analysis (81240, 81241). 
 You asked the Plan to pre-approve F2 gene analysis and F5 gene analysis. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that molecular pathology procedures are covered when 
specific criteria 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 F2 gene analysis and F5 gene analysis. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found the requested 
testing is not medically necessary. The review has determined that the enrollee does not meet the coverage 
criteria detailed in the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of F2 gene analysis and F5 gene analysis have not been met. Therefore, we 
decided that the Plan does not have to pre-approve F2 gene analysis and F5 gene analysis (81240, 81241).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator system. 
 
You asked the Plan to pre-approve a home ventilator system. You say that the enrollee has horrible respiratory 
failure and was in the hospital because of it. The Plan denied your request. The Plan says a home ventilator is 
not medically necessary for this patient because their needs can be met with an alternative device such as a 
BiPAP device with average volume-assured pressure support (AVAPS).   
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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 home ventilator system. Our reviewer 
says that a home ventilator system is not medically necessary. Our physician reviewer found that there is no 
documented failure of CPAP or BiPAP. Also, there is no supportive data or documentation to support 
escalation to a home ventilator. Therefore, a home ventilator would not be the best practice at this time given 
the documentation 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 a home ventilator system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a home ventilator system.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the application of the Matrion skin substitute graft 
(15271, Q4201). 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the requested service 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 this service. Our reviewer says that the 
requested service is not medically necessary. Our physician reviewer found that the medical documentation 
supports that this enrollee is suffering with an open ulceration to the left lower extremity. Lower extremity 
edema with venous stasis is noted. The ulceration is considered a venous stasis ulceration.  
  
 
Medicare advises that they will pay for items or services that are considered medically reasonable or necessary 
for the treatment of an illness or injury. These treatments must be safe and effective, not mainly for the 
convenience of the patient or the physician, appropriate in that they are furnished in accordance with accepted 
standards of medical practice for the diagnosis or treatment of the patients condition, one that meets but does 
not exceed the patients medical need, and at least as beneficial as an existing and available medically 
appropriate alternative. In this particular case, the enrollee presented to you stating that the open ulceration had 
been present for roughly one month. The medical documentation does not demonstrate prior prolonged 
conservative wound care. Nor does the medical documentation support that the enrollee has undergone 
treatment for her venous stasis including serial Unna boot applications, or elevation of the lower extremity. It 
does not appear as though the enrollee has undergone sufficient conservative treatments including serial wound 
care, and addressing of the venous stasis to the lower extremity. It does not appear that the application of the 
Matrion skin substitute is medically reasonable or 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 this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the application of the Matrion skin substitute graft (15271, Q4201).