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

We decided that the Plan does not have to pay for home infusion therapy services (HCPCS S9328) for the
enrollee.
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your
request. The Plan says this code is not payable by Medicare.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of HCPCS code S9328 is "Home infusion therapy, implanted
pump pain management infusion; administrative services, professional pharmacy services, care coordination,
and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem (pain pump
therapy)."
We find that HCPCS code S9328 is not supported in the medical record. Specifically, this code has a status
indicator of I according to the Medicare Physician's Fee Schedule. This indicates that the code is not valid for
Medicare purposes. 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 home infusion therapy services
(HCPCS S9328) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapy services provided on August 29, 2019 to August 30, 2019 by an out of network (OON) provider.
You asked the Plan to pay for these OON services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
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 has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the therapy services provided on August 29, 2019 to August 30, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for assisted living services provided on December 24, 2019 by an out of network (OON) provider.You asked the Plan to pay for assisted living services. You say that your provider cannot deny services that are essential for the patient's health treatment.The Plan denied your request. The Plan says they did not authorize any services with this provider or facility.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 has network providers available who can provide 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 assisted living services provided on December 24, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on December 30, 2019.
You asked the Plan to waive the copayment for the office visit. You say that the visit was to select the provider as your primary care physician. You say that you should not have been obligated to pay a specialist copayment. The Plan denied your request. The Plan says the copayment 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 $40 copayment for provider and professional services at an in-network specialist's office. You have been asked to pay a $40 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show that the office visit was at a cancer center, which is considered a specialist's office. 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 the office visit provided on December 30, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says the records show that the enrollee has an ileus, and needs to complete the full course of care in the hospital.
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 is currently undergoing treatment at an ACH for a stroke and limb ischemia. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs. 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 admission to a long term acute care hospital (LTACH) for the enrollee for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hydroxyzine tablets.
You asked the Plan to pre-approve Hydroxyzine. You say that this medication has helped the enrollee with their itching. You also say that the enrollee has used multiple creams and ointments without signs of improvement. The Plan denied your request. The Plan says this drug is not covered for the enrollee's condition under Medicare 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 Hydroxyzine tablets.
Benefits for Hydroxyzine 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the lab services you received on January 21, 2020.You asked the Plan to waive the cost share for the lab services. You say that you were told the services would be covered in full.The Plan denied your request. The Plan says you are financially liable for cost sharing applied, and services that are not medically necessary.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 30% coinsurance for out-of-network Medicare-covered lab test. You have been asked to pay a 30% coinsurance for the out-of-network lab services billed with procedure codes 81402, 81291, 81231, and 81230. The lab services fall within the outpatient diagnostic tests 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.The file shows that you received genetic testing for the CYP2C19, CYP2D6, CYP2C9, and other unlisted molecular pathology procedures. 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 remaining lab testing. Our physician review found that you have a diagnosis of major depressive disorder, post-traumatic stress disorder, attention deficit hyperactivity disorder, panic disorder and compression of brain.Genetic testing was ordered due to trial and failure of multiple medications.Based on the medical records provided and the coverage criteria, the genetic testing was not medically reasonable and necessary. Therefore, we decided that the Plan does not have to waive the cost share for the lab services you received on January 21, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to provide monthly injections of Nucala.
You asked the Plan to provide monthly injections of Nucala. You say that there is a high likelihood that this medication will provide substantial benefit to the enrollee. The Plan denied your request. The Plan says the enrollee does not have a qualifying diagnosis.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 provide monthly injections of Nucala. Our reviewer says that the enrollee does not qualify for this medication. Our physician reviewer found the enrollee is currently under care for moderate persistent asthma. The enrollee has continued to have significant breakthrough symptoms despite therapy with Symbicort on a regular basis and intermittent QVAR during flare-ups. The enrollee uses albuterol as a rescue and has been prescribed lncruse for persistent asthma symptoms. In this case, the enrollee does not have severe asthma and does not have significant eosinophilia that would qualify. The provider used moderate persistent asthma, uncomplicated as a diagnosis. The review has determined that the requested use of Nucala is not FDA-approved for the enrollee's diagnosis. The use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal (see appendix for list of CMS-approved journals). The use listed as not indicated, not supported or not recommended in any of the compendia. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of monthly injections of Nucala have not been met. Therefore, we decided that the Plan does not have to provide monthly injections of Nucala.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on December 19, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services 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 documentation/records of the ordering physician's intent that the tests 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 December 19, 2019
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspiration with surgical assistant.You asked the Plan to pre-approve bone marrow aspiration. You say that the enrollee is in severe pain.The Plan denied your request. The Plan says the denial of authorization for this service is correct, because studies have not proven that this procedure is helpful for the enrollee's condition.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 bone marrow aspiration. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found bone marrow aspiration remains experimental for use in cases of spinal fusion. More research is needed to show the efficacy of this procedure.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of bone marrow aspiration have not been met.Therefore, we decided that the Plan does not have to pre-approve bone marrow aspiration with surgical assistant.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from July 22, 2019 to August 9, 2019.You asked the Plan to pay for home health services. You say that you would like reconsideration as this claim has been billed correctly.The Plan denied your request. The Plan says the claim was submitted with inappropriate home health data to process and pay claims.The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered.We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the submitted claim has not been billed with all of the required home health data, such as the treatment authorization code, Q code, appropriate type of bill or revenue code.Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from July 22, 2019 to August 9, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH).
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says the clinical information received did not establish medical necessity for an inpatient hospital admission to a long-term care facility.
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 based on the provided medical records, the acute care hospital is able to provide all of the services that you require. You are receiving necessary services and are at an appropriate level of care in the acute care hospital. Continued care at this level is appropriate until you are stable to transfer to a lower level of care such as an inpatient rehabilitation facility, a skilled nursing facility, sub-acute rehabilitation facility or home with home health 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for naturopath services received on December 31, 2019.You asked the Plan to pay for the services. You say that you were referred here by your PCP, as he does not perform these services at your office.The Plan denied your request. The Plan says these services are explicitly not listed as a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not cover naturopathic services. The services at issue in this appeal are naturopathic services. The plan does cover some naturopath-related services -acupuncture and chiropractic services. The services are received do not fall under this covered category, as it is IV chelation.Therefore, we decided that the Plan does not have to pay for naturopath services received on December 31, 2019.
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 the enrollee needs daily physician monitoring, lab work, and wound care.The Plan denied your request. The Plan says the enrollee does not need further complex hospital or nursing care.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 physician reviewer found LTACHs are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing care needs include telemetry, intravenous antiviral, surveillance laboratory studies, transfusions as indicated, wound care, and therapy services. The documentation does not support that the enrollee requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four testing (95999) provided on October 30, 2019.
You asked the Plan to pay for train of four testing. You say that this was medically necessary. The Plan denied your request. The Plan says payment of this service is bundled into other services.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 95999 is not supported in the medical record. Specifically, the use of unlisted CPT code 95999 to report train of four testing is not supported. According to CPT coding rules, train of four testing is not a separately reportable procedure and is included in the other interoperative neuromonitoring procedures. Based on this information, we decided that Medicare rules for coverage of train of four testing have not been met. Therefore, we decided that the Plan does not have to pay for train of four testing (95999) provided on October 30, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0675, E0673). You asked the Plan to pay fora pneumatic compression device. You say that the device is necessary to prevent deep vein thrombosis.The Plan denied your request. The Plan says the pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery.The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism is a preventive service.We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage.Therefore, we decided that the Plan does not have to pay fora pneumatic compression device (E0675, E0673).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of an interspinous stabilization device (Vertiflex).
You asked the Plan to pre-approve Vertiflex procedure. You say that you are appealing based on medical necessity. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this procedure is not generally considered safe and helpful.
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 Vertiflex procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental. More research is needed to show the safety and efficacy of the Vertiflex procedure. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of an interspinous stabilization device (Vertiflex).