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

 
We decided that the Plan does not have to pre-approve chromoendoscopy. 
 
You asked the Plan to pre-approve chromoendoscopy. 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 chromoendoscopy. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found given the frequency of surveillance, the success thus far in polyp detection and 
resection, and the consideration of at least partial colectomy, the medical appropriateness and necessity of 
chromocolonoscopy in lieu of conventional optical colonoscopy is not apparent. There is little likelihood that chromocolonoscopy will alter the enrollee's already aggressive non-operative 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 chromoendoscopy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve chromoendoscopy.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on August 22, 2023. 
 You asked the Plan to pay for the ambulance services. You say that the enrollee was not on hospice on this 
date. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for ambulance services provided on August 22, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on February 16, 2023. 
 You asked the Plan to pay for the lab services. You say that the services were not related to the enrollee's 
hospice diagnosis. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for laboratory services provided on February 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on July 12, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service March 20, 2023, and 
May 4, 2023. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) 
provided on July 12, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy to be provided by an OON provider.  
 
You asked the Plan to pre-approve physical therapy. You say that the requested provider is in the Medicare 
network. The Plan denied your request. The Plan says you must receive your care from a network provider.  
 
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 to be provided by an OON provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transportation services to from your home to your 
doctors office.  
 
You asked the Plan to pre-approve the transportation services. You say that the services are medically 
necessary. The Plan denied your request. The Plan says the requested services are not a covered benefit. 
 
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 pre-approve are ambulance transport services to a doctors office. 
Therefore, we decided that the Plan does not have to pre-approve transportation services to from your home to 
your doctors office.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on June 9, 2023. You asked the Plan to pay for the ambulance services. You say that the enrollee required ambulance transport 
due to current medical status. The Plan denied your request. The Plan says transportation to and from a doctor's 
office is not a Medicare covered benefit. 
 
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 ambulance services provided on June 9, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment without transport 
services received on June 19, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment without transport services. You say that 
the services were medically necessary. The Plan denied your request. The Plan says without transport there are 
no payable services. 
 
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 June 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 response and treatment without 
transport services received on June 19, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies provided on 
August 16, 2023. You asked the Plan to pay for the CGM supplies. You say that you have submitted documentation and the 
claim should be paid. The Plan denied your request. The Plan says Original Medicare is responsible for 
payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies provided on 
August 16, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance treatment without transport provided on July 14, 
2023. 
 
You asked the Plan to pay for the ambulance treatment without transport. You say that you did not go to the 
hospital. The Plan denied your request. The Plan says the Medicare ambulance benefit is a transportation 
benefit and without a transport there is no payable 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 July 14, 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 ambulance treatment without transport provided 
on July 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for complete maxillary denture rebase (D5710) provided on June 
19, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they were 
performed by a denturist. 
 
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, treatment cannot be performed by 
someone other than a dentist, except for scaling, teeth cleaning and the topical application of fluoride. 
Therefore, we decided that the Plan does not have to pay for complete maxillary denture rebase (D5710) 
provided on June 19, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance treatment without transport provided on October 
15, 2022. 
 
You asked the Plan to pay for the ambulance treatment without transport. You say that the transport was not 
needed since you were able to drive yourself. The Plan denied your request. The Plan says the Medicare 
ambulance benefit is a transportation benefit and without a transport there is no payable 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 October 15, 2022. 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 ambulance treatment without transport provided 
on October 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a hospital bed (E0260). 
 
You asked the Plan to pre-approve the hospital bed. You say that the hospital bed is medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that a hospital bed may be considered medically necessary 
when at least one of the following criteria is met: 
 
1. The patient has a medical conditions which requires positioning of the body in ways not feasible with an 
ordinary bed; or 
 
2. The patient requires positioning of the body in ways not feasible with an ordinary bed in order to alleviate pain; or 
 
3. The patient requires the head of the bed to be elevated more than 30 degrees most of the time due to 
congestive heart failure, chronic pulmonary disease, or problems with aspiration. Pillows or wedges must have 
been considered and ruled out; or 
 
4. The patient requires traction equipment, which can only be attached to a hospital bed. 
 
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 hospital bed. Our reviewer says that 
the hospital bed is not medically necessary. Our physician reviewer found the records provided do not support 
the request.   
 
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 hospital bed have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a hospital bed (E0260).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a low dose computed tomography (LDCT) scan for lung 
cancer screening. 
 
You asked the Plan to pay for the requested LDCT scan. You say that the claim was denied as a duplicate in 
error. The Plan denied your request. The Plan says the enrollee had an LDCT performed within the last 12 
months. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung 
cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.  
 
We reviewed the file and the Medicare rules. We find that the enrollee had an LDCT performed within the last 
12 months. Therefore, we decided that the Plan does not have to pay for a low dose computed tomography 
(LDCT) scan for lung cancer screening.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee orthosis (L1845). 
 
You asked the Plan to pre-approve the knee orthosis. You say that this item is medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that knee orthoses L1832, L1833, L1843, L1845, L1851 
and L1852 are covered for a beneficiary who is ambulatory and has knee instability. 
 
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 knee orthosis. Our reviewer says 
that the knee orthosis is not medically necessary. Our physician reviewer found the records do not show knee 
instability or recent surgery. 
 
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 knee orthosis have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a knee orthosis (L1845).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance treatment without transport provided on June 9, 
2023. 
 
You asked the Plan to pay for the ambulance treatment without transport. You say that you were advised that 
you did not need to go to the hospital. The Plan denied your request. The Plan says the Medicare ambulance 
benefit is a transportation benefit and without a transport there is no payable 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 June 9, 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 ambulance treatment without transport provided 
on June 9, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the bone marrow aspirate. 
 
You asked the Plan to pre-approve the bone marrow aspirate. You say that this is medically necessary. The 
Plan denied your request. The Plan says the clinical value and effectiveness of a bone marrow aspirate has not 
been demonstrated in 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 the bone marrow aspirate. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no specific indication provided to support the request for the bone marrow 
aspirate for the approved surgery. There is a lack of large volume, long-term peer-reviewed outcome studies to 
support the use of bone marrow aspirate for this enrollees medical condition as discussed above. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. 
 
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 bone marrow aspirate have not been met. Therefore, the requested bone 
marrow aspirate is not medically reasonable or necessary.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transport services received on August 1, 2023. 
 
You asked the Plan to pay for the transport services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says wheelchair van transport is not a covered service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport 
services.  
 
The services you have asked the Plan to pay for are wheelchair van transport services. Therefore, we decided 
that the Plan does not have to pay for the transport services received on August 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the full cost for the chiropractic manipulative treatment and 
the electrical stimulation provided by a chiropractor on July 31, 2023. 
 
You asked the Plan to pay for the full cost for the chiropractic manipulative treatment and the electrical 
stimulation. You say that your deductible should be $40 not $60 for the service. The Plan denied your request. 
The Plan says the chiropractic manipulative treatment processed correctly with a $20 copayment and the 
remaining services are denied as they are not a covered chiropractic service. 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The rules says that the only chiropractic service Medicare covers is 
manipulation of the spine to correct subluxation.  
 
You have been asked to pay a $20 copayment for the chiropractic manipulative treatment. This item/service 
falls within the Chiropractic Services benefit category. In addition the electrical stimulation remain denied as it 
is not a covered chiropractic service. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. Therefore, we decided that the Plan does not have to pay for the full cost for the 
chiropractic manipulative treatment and the electrical stimulation provided by a chiropractor on July 31, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the ventilator was prescribed to help 
manage the enrollee's pulmonary exacerbations at home. The Plan denied your request. The Plan says a review 
of the current medical literature does not support the Life2000 device to be reasonable and necessary. 
 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. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has COPD and coronary 
artery disease and is on home supplemental oxygen. There is no diagnosis of thoracic restrictive disease or 
neuromuscular disease. The Life2000 system is not a true ventilator because it is not capable of providing full 
ventilatory support. It is intended to be used during activity, and there is inadequate evidence that it is 
beneficial in the treatment of any chronic lung disease. 
 
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 have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee is at high risk for hospital 
readmission and potentially life-threatening exacerbations. The Plan denied your request. The Plan says the 
enrollee does not meet criteria for approval of the requested ventilator. 
 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. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has obesity 
hypoventilation syndrome and suspected obstructive sleep apnea. The enrollee was hospitalized after 
undergoing total knee replacement, with acute kidney injury and arterial blood gas consistent with acute on 
chronic hypercarbic respiratory failure. There is no diagnosis of COPD, thoracic restrictive disease, or 
neuromuscular disease. This enrollee may benefit from BiPAP during sleep as an outpatient. The records do 
not show this has been tried and failed as an outpatient. Volume assurance can be provided with a BiPAP 
device, if needed. Medicare does not cover a home ventilator when used at settings that can be provided with 
BiPAP. Very high inspiratory pressures beyond what can be provided with BiPAP, and battery backup, are not 
medically necessary. The denial is upheld. 
 
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 have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).