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

 
We decided that the Plan does not have to pay for the shingles vaccine (90750 and 90472) provided on June 3, 
2020. 
 
You asked the Plan to pay for the shingles vaccine. You say that you would like reconsideration because this 
should be a covered benefit. The Plan denied your request. The Plan says this vaccine is only covered under 
Part D plans. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the shingles 
vaccine. Therefore, we decided that the Plan does not have to pay for the shingles vaccine (90750 and 90472) 
provided on June 3, 2020. 
 
Benefits for the shingles vaccine may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Praluent. 
 
You asked the Plan to pre-approve Praluent.. You say that the enrollee has been using Praluent, and it has been 
working well for her. The Plan denied your request. The Plan says this medication does not fall under Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Praluent.  
 
Benefits for Praluent. may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $45 specialist copayment charged for physician services 
provided on June 8, 2020. 
 
You asked the Plan to waive this copayment. You say that you do not believe this copayment is correct. The 
Plan denied your request. The Plan says this copayment was charged based on the Plan contract agreement. 
 
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 $45 
copayment for specialist services (including telehealth specialist services). 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 $45 
specialist copayment charged for physician services provided on June 8, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient hospital observation provided 
from June 17, 2020, to June 18, 2020. 
 
You asked the Plan to waive the copayment for outpatient hospital observation. You say that the nurses were 
cold and uncaring and you disagree with the charges. The Plan denied your request. The Plan says the claims 
were processed correctly and you are being charged the correct 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 $395 
copayment for outpatient hospital observation.  
 
You have been asked to pay a $395 copayment for outpatient hospital observation. outpatient hospital 
observation falls within the outpatient hospital observation 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 outpatient hospital observation provided from June 17, 2020, to June 18, 2020.  
 
We note your complaint that the nurses were rude and cold toward you. Your complaint is a grievance that 
must be answered by the health plan. Medicare does not permit us to make a decision about these types of 
complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve20 additional routine transportation trips.You asked the Plan to pre-approve20 additional routine transportation trips. You say that you need additional trips to get to the hospital and your family doctor.The Plan denied your request. The Plan says you have exhausted your routine transportation benefit.Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 48 trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation.Therefore, we decided thatthe Plan does not have to pre-approve20 additional routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the implant supported porcelain fused to metal crown on 
tooth #14 provided on June 3, 2020. 
 
You asked the Plan to pay for implant supported crown. You say that you needed the crown for an implant that 
was done last year. You also say that you feel this should be covered, because crowns are a covered benefit 
under your plan. The Plan denied your request. The Plan says tooth #14 is a posterior (back) tooth. The Plan 
also says that implant services that replace posterior (back) teeth are not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, implant services are limited to 
replacing a single missing anterior (front) tooth. The record shows that the implant was used on tooth #14, 
which is a posterior tooth, and is not a covered implant benefit. Therefore, we decided that the Plan does not 
have to pay for the implant supported porcelain fused to metal crown on tooth #14 provided on June 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the outpatient hospital services rendered 
on May 11, 2020 and May 18, 2020. 
 
You asked the Plan to waive the copayments for these services. You say that you disagree with the charges. 
The Plan denied your request. The Plan says the copayments were applied correctly. 
 
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 $175 
copayment for each in-network Medicare-covered outpatient hospital facility visit.  
 
Review of the file shows that you received outpatient hospital services on May 11, 2020 and May 18, 2020. 
You have been asked to pay a $175 copayment per date of service for these services, for a total of $350. These 
services fall within the in-network Medicare-covered outpatient hospital facility visit 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 copayments for the outpatient hospital services rendered on May 11, 2020 
and May 18, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient care provided from December 14, 2019, to 
December 16, 2019. 
 
You asked the Plan to pay for the inpatient care. The Plan denied your request. The Plan says the inpatient care 
was not medically necessary. 
 
 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the inpatient care. Our reviewer says that the 
requested inpatient post-stabilization care was not medically reasonable and necessary. Our physician reviewer 
found that the enrollee was hemodynamically stable and appropriate for ambulance transport with monitoring 
to a Plan facility for observation/admission level of care services after the emergency room evaluation on 
December 13, 2019. There was no documentation provided necessitating post-stabilization care services at the 
non-Plan facility. The treating physician document (in the physician notes, on a form, or in an order) that the 
patient was not stable for transfer on any dates of service. 
 
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 inpatient care have not been met. Therefore, we decided that the Plan does 
not have to pay for the inpatient care provided from December 14, 2019, to December 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neurolysis facet nerve injections. 
 
You asked the Plan to pre-approve the neurolysis facet nerve injections. You say that the records provided 
support the need for the requested injection services. The Plan denied your request. The Plan says the records 
 
 
do not show that the enrollee's doctor has confirmed facet joint pain was improved by at least 80% following 
each of two medial branch blocks. 
 
The Plan follows Medicare rules. Medicare rules say that Facet Joint Interventions are considered medically 
reasonable and necessary for the diagnosis and treatment of chronic pain in patients who meet specific criteria. 
 
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 neurolysis facet nerve injections. 
Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the requested 
procedure is supported for predominantly axial pain that is not associated with radiculopathy or neurogenic 
claudication. The office notes indicate the patient has chronic low back pain with radiation into the right and 
left legs and feet. Dual medial branch blocks (MBBs) did not provide more than 80% relief of the primary or 
index pain. The requested injections are not medically reasonable and necessary to treat 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 neurolysis facet nerve injections have not been met. Therefore, we decided 
that the Plan does not have to pre-approve neurolysis facet nerve injections.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a DaTscan. 
 
You asked the Plan to pre-approve the DaTscan. You say that the enrollee is showing signs of Parkinson's . The 
appellant says that the requested imaging is medically necessary and that, because the enrollee is having 
cognitive decline and they need to start treatment. The Plan denied your request. The Plan says the imaging 
requested is not supported because it is not needed to confirm if the enrollee's problem is one of type types of 
movement disorders. The Plan says that the records do not show that the enrollee has had any drug trials. 
 
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 DaTscan. Our reviewer says that the 
requested DaTscan is not considered medically reasonable and necessary in this case. Our physician reviewer 
found, while there is clinical utility in performing a DaTscan in ruling in a diagnosis of Parkinson's Disease 
and/or separating PD from a diagnosis of essential tremor, the utility of such testing is less defined in other 
syndromes. It has not readily been shown to be of diagnostic utility in secondary parkinsonism either. The 
enrollee's differential diagnosis of "lower half Parkinson's" is not one that is readily associated with changes in 
the dopaminergic system. Rather this is classified as a secondary parkinsonism within current literature. 
Therefore, the proposed imaging study would not be of diagnostic or clinical utility and would not reflect 
services that are otherwise consistent with the generally accepted standards of practice or care. Such testing 
may otherwise exceed that which is necessary for the evaluation of his condition. In as much this service would 
not meet the Medicare definition of medical necessity 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 the DaTscan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a DaTscan.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia for the enrollee. 
 
You asked the Plan to pre-approve Prolia. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not covered under Part B. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Prolia for the enrollee.  
 
Benefits for Prolia may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient psychiatric services. 
 
You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says the enrollee 
is medically stable and does not require 24-hour inpatient care. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
The documentation shows that continued inpatient services from October 14, 2020, forward, were requested for 
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 continued services. Our 
physician reviewer found that active treatment was not taking place. It did not appear that the services were 
reasonably expected or medically necessary to improve the enrollee's condition, or for the purpose of 
diagnosis. It appears that the services were supervised and evaluated by a physician. Based upon review the 
records provided, this enrollee could be treated in a lesser restrictive setting as he was not showing any suicidal 
or homicidal ideation, auditory or visual hallucinations, and was not showing any behaviors being cooperative 
and compliant. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve continued inpatient psychiatric services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with accessories. 
 
You asked the Plan to pre-approve Group 3 power wheelchair. You say that you are appealing. The Plan denied 
your request. The Plan says the denial of authorization for this device is correct, because the enrollee does not 
need this Group 3 power wheelchair. 
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
1. A neurological condition; 
2. Myopathy; or 
3. Congenital skeletal deformity. 
 
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 Group 3 power wheelchair. Our 
reviewer says that the enrollee does not meet the Medicare criteria for a Group 3 power wheelchair. Our 
physician reviewer found the enrollee is noted to have a mobility limitation, but the documentation does not 
indicate that this mobility limitation is due to a neurological condition, myopathy, or congenital skeletal 
deformity. Furthermore, it is not clear that the enrollee has the cognitive function that would enable safe use of 
a Group 3 power wheelchair. She is noted to have short-term memory deficits which would not indicate that 
she would have good carry-over with training in power mobility wheelchair use. Therefore, this device 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 Group 3 power wheelchair have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Group 3 power wheelchair with accessories.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on April 24, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code cannot 
be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab 
requisition stating exactly which testing was to be performed. 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 pay for the drug testing services provided on April 24, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care. 
 
You asked the Plan to pre-approve inpatient psychiatric care. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has 
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 inpatient psychiatric care. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found based upon review of the records provided, the enrollee does not meet the criteria for 
acute inpatient mental health treatment as this enrollee was not shown to be a danger to himself or others. The 
enrollee was without agitation or aggression and without perceptual disturbance including auditory, visual 
hallucinations or delusions. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient psychiatric care.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for ambulance services (A0425 and A0427) provided on April 17, 2020. 
 
 
You asked the Plan to pay for the ambulance services. You say that you would like reconsideration because the 
ambulance services were medically necessary. The Plan denied your request. The Plan says that the member 
could have been safely transported by another type of motor vehicle, possibly a van transport vehicle. 
 
Medicare pays for ambulance services only when an emergency exists or when other means of transport would 
endanger the patient's health. 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 ambulance services. Our reviewer says 
that the ambulance services were medically reasonable and necessary. Our physician reviewer found shortness 
of breath has potential of rapidly progressing and a patient with shortness of breath should not be transported 
without assistance. 
 
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 ambulance services have not been met. Therefore, we decided that the Plan 
has to pay for ambulance services (A0425 and A0427) provided on April 17, 2020. 
  
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.