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

 
We decided that the Plan does not have to pay for medical nutrition therapy provided on provided on  
May 20, 2021 
 
You asked the Plan to pay for medical nutrition therapy services. You say that this provider is a registered 
dietitian who is able to bill code 97802. The Plan denied your request. The Plan says based on Medicare 
guidelines the medical nutrition therapy you are requesting does not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes.  
 
Records do not show that the enrollee suffers from renal disease or diabetes. Therefore, we decided that the 
Plan does not have to pay for medical nutrition therapy provided on provided on May 20, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Sanexas device and therapy provided to the enrollee 
on October 28, 2021. 
 
You asked the Plan to pre-approve the services. You say that this should be paid for. The Plan denied your 
request. The Plan says this is considered an experimental treatment. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that this therapy is considered experimental. The review indicates that the services at issue in this case 
are not medically reasonable or necessary. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Sanexas device and therapy provided to the enrollee on October 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a physician office visit (99213) provided on February 23, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a physician office visit. You say that the service at issue was a medical necessity 
for you. The Plan denied your request. The Plan says rules for payment for out-of-network care 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 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 a physician office visit (99213) provided on 
February 23, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you would like to appeal the denial of 
the claim. The Plan denied your request. The Plan says The member is receiving appropriate in-patient acute 
care and does not require transfer to a Long-Term Acute Care Hospital (LTACH). 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found The enrollee does not require services at the LTACH that are not available at the 
acute care hospital where he/she is currently receiving care. All medically necessary care is being provided in 
the current acute care setting.  
 
There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the health plan. The health plan has approved ongoing care in the current acute care 
setting.   
The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on May 6, 
2021. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that you were unaware that 
there was a copayment for the visit. The Plan denied your request. The Plan says the proper copayment was 
applied for the service that was rendered. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for each Specialist visit.  
 
  You have been asked to pay a $40 copayment for the specialist office visit. The specialist office visit falls 
within the Physician/Practitioner services, including doctors office visits benefit category. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for a specialist office visit provided on May 6, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve spinal surgery for the enrollee. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says this surgery 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 the surgery. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is no spinal instability, fracture, or lesion. The L4-5 is stable, as the films do not show 
instability. 
 
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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve spinal surgery for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that an LTACH admission is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for 
coverage of an LTACH admission. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where he is currently receiving care. All medically necessary care is being provided in the 
current acute care setting.  
 
 
 There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the health plan. The health plan has approved ongoing care in the current acute care 
setting.  
 
The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve two levels of facet blocks. We decided that the Plan does not have 
to pre-approve the other two levels of facet blocks.  
 You asked the Plan to pre-approve four levels of facet blocks. You say that you would like the plan to 
reconsider their denial. The Plan says that the requested services are not medically necessary. 
 
We decided that the Plan has to pre-approve two levels of facet blocks.  
 
The Plan follows Medicare rules. Medicare rules say that only one or two levels may be treated at one session 
 
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 four levels of facet blocks. Our 
reviewer says that the documentation does not support that more than two levels of facet blocks are medically 
reasonable or necessary. Our physician reviewer found the enrollee has chronic low back pain. This request 
exceeds utilization criteria.  Only one or two levels may be treated at one session. Therefore, the request for 
two levels to be specified by the physician is medically reasonable and necessary.  
 
We also decided that the Plan does not have to pre-approve the other two levels of facet blocks. 
 
The Plan follows Medicare rules. Medicare rules say that only one or two levels may be treated at one session. 
 
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 other two levels of facet blocks have not been met. Therefore, we decided 
that the Plan has to pre-approve two levels of facet blocks and that the Plan does not have to pre-approve the 
other two levels of facet blocks. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton therapy for prostate cancer. 
 
You asked the Plan to pre-approve proton therapy for prostate cancer. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested services are 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 proton therapy for prostate cancer. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found you have prostate cancer. There are no randomized trials comparing proton 
beam therapy with photon therapy or brachytherapy in men with clinically localized prostate cancer. A 
systematic review of the available evidence from American Society for Radiation Oncology (ASTRO) on 
efficacy and toxicity concluded that outcomes were similar with proton beam therapy and intensity-modulated 
radiation therapy (IMRT) using photons but did not demonstrate a benefit for the proton beam approach.  
Clinical practice guidelines form the American Urological Association (AUA)/American Society for Radiation 
Oncology (ASTRO)/Society of Urologic Oncology (SUO)/American Society of Clinical Oncology (ASCO) conclude that proton beam therapy offers no clinical advantage over other forms of definitive treatment. The 
NCCN Panel believes no clear evidence supports a benefit or decrement to proton therapy over IMRT for either 
treatment efficacy or long-term toxicity. Conventionally fractionated prostate proton therapy can be considered 
a reasonable alternative to x-raybased regimens at clinics with appropriate technology, physics, and clinical 
expertise. Therefore, you do not meet criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of proton therapy for prostate cancer have not been met. Therefore, we decided 
that the Plan does not have to pre-approve proton therapy for prostate cancer.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the orthoses provided on March 8, 2022. 
 
You asked the Plan to pay for the services provided. You say that the records request was completed. The Plan 
denied your request. The Plan says the claim denied correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that orthoses are only covered under certain medical 
indications. 
 
The file shows that a prefabricated foot (L3170) was provided. The records provided do not show that this item 
is an integral part of a covered brace. The file also shows that an ankle-foot orthosis (L1971) was provided. The 
records do not show that the enrollee was experiencing weakness or deformity, requiring stabilization. Based 
on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that 
the Plan does not have to pay for the orthoses provided on March 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator (E0466). 
 
You asked the Plan to pre-approve a portable ventilator. You say that the requested device is medically 
necessary. The Plan denied your request. The Plan says the requested device does not meet criteria. 
 
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. 
 
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 ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has severe COPD with a 
recent hospitalization. VBG suggests CO2 retention but there is no ABG done while stable to confirm chronic 
CO2 retention. The enrollee may benefit from ventilatory support during sleep with bipap in the AVAPS mode. 
This has not been tried. Medicare does not cover a home ventilator when used as bipap. 
 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 ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 power wheelchair (PWC). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a Group 2 PWC is 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records show you have a history of 
a stroke with mobility impairment. You have difficulty with community-level ambulation. The evaluation from 
the physical therapist states that the PWC is not medically necessary due to safety concerns with operating a 
powered mobility device. The criteria for coverage are not met and the services are therefore not reasonable or 
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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Group 2 power wheelchair (PWC).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electrical bone growth stimulator. 
 
You asked the Plan to pre-approve an electrical bone growth stimulator. You say that this device is medically 
reasonable and necessary. The Plan denied your request. The Plan says the criteria for coverage have not been 
met. 
 
The Plan must follow Medicare rules. The rules say that an electrical bone stimulator is covered for nonunion 
of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial radiographs 
have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment with the 
electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs 
separated by a minimum of 90 days.  
 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 electrical bone growth stimulator. 
Our reviewer says that the requested electrical bone growth stimulator is not medically reasonable and 
necessary. Our physician reviewer found the enrollee is a 75-year-old female with past medical history of fall 
resulting in left third metacarpal fracture, b/l distal radial fractures and right radial head fractures. In this case, 
the criteria requiring clinical evidence of non-union for at least 90 days have not been met. Therefore, the 
requested electrical bone growth stimulator is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an electrical bone growth stimulator have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an electrical bone growth stimulator.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve myocardial perfusion imaging, tomographic (SPECT) 
(78452). 
 
You asked the Plan to pre-approve nuclear stress testing. You say that the requested service is medically 
necessary. The Plan denied your request. The Plan says the requested service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that stress testing with cardiac imaging will be considered 
medically reasonable and necessary for certain situations. 
 
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 nuclear stress testing. Our reviewer 
says that the requested nuclear stress testing is not medically necessary. Our physician reviewer found there is 
no documentation that the electrocardiogram (ECG) shows an uninterpretable pattern. There is no evidence 
provided that would support the need for radionuclide stress testing. Therefore, the reviewer found there is 
insufficient documentation to support the medical necessity for the requested cardiac stress testing. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of nuclear stress testing have not been met. Therefore, we decided that the Plan 
does not have to pre-approve myocardial perfusion imaging, tomographic (SPECT) (78452).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
April 18, 2022. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you tried to go to an imaging center 
but needed a referral, and the hospital was the only option. The Plan denied your request. The Plan says you 
have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $120 
copayment for each emergency room visit.  
 
You have been asked to pay a $120 copayment for the ER visit. The ER visit falls within the Emergency Care 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for an emergency room (ER) visit 
provided on April 18, 2022.