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

We decided that the Plan does not have to pay for chemotherapy administration (96413, 96417, and 96375) provided on August 28, 2019.You asked the Plan to pay for chemotherapy administration. You say that these services were required.The Plan denied your request. The Plan says these codes are not supported by the records.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 code 96413 is chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug;96417 is chemotherapy administration, intravenous infusion technique; each additional sequential infusion (different substance/drug), up to 1 hour (List separately in addition to code for primary procedure); and 96375 is therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of a new substance/drug (List separately in addition to code for primary procedure). We find that CPT code 96413, 96417, and 96375 are not supported in the medical record. Specifically,96413 and 96417 are time based codes. The record does not include documentation of the time spent on these procedures. Code 96375 is an add-on code that cannot be paid when the primary procedure is denied. Based on this information, we decided that Medicare rules for coverage of chemotherapy administration have not been met.Therefore, we decided that the Plan does not have to pay for chemotherapy administration (96413, 96417, and 96375) provided on August 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the neurostimulator treatments provided from July 16, 2019 through September 10, 2019.
You asked the Plan to waive the copayments for the neurostimulator treatments. You say that you were not informed you were being admitted to the hospital on an outpatient basis. You say that you were not informed you would have a $100 copayment for each treatment. The Plan denied your request. The Plan says the copayments 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 $100 copayment for each outpatient hospital visit. You have been asked to pay a $100 copayment for each neurostimulator treatment. The total amount you owe is $700 ($100/treatment x 7 treatments = $700). Neurostimulator treatments falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 neurostimulator treatments provided from July 16, 2019 through September 10, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home elevator repairs.You asked the Plan to pre-approve the repairs. You say that this should be reconsidered for reimbursement.The Plan denied your request. The Plan says the elevator itself is not covered, so repairs also can't be covered.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plan does not have to pre-approve home elevator repairs.
Appeal type: SNF
Decision: Unfavorable

rollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied
your request. The Plan says the enrollee does not have daily skilled nursing needs.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above are met. Custodial care is 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 admission. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled
nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely
and effectively provide medically necessary and reasonable treatment. The enrollee does not have complex
wound care or other SNF level skilled nursing need. This enrollee's function is near baseline and does not
require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist
required to safely and effectively provide medically necessary and reasonable treatment. The enrollee does not
require these skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis".
As a practical matter this enrollee does not require the necessary services on an inpatient basis, in a skilled
nursing facility setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided thatMedicare rules for coverage of the admission have not been met. Therefore, we decided that the Plan does not
have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for sterile water (A4216), supplies for maintenance of noninsulin
drug infusion catheter (A4221), infusion supplies for external drug infusion pump (A4222), an injection
of dobutamine hydrochloride (J1250), and an injection of heparin sodium (J1644) provided on August 21, 2019
to August 27, 2019 by the out of network provider.
You asked the Plan to pay for injections and supplies. You say that you are seeking a review and requesting
payment as you were not told an authorization was needed. The Plan denied your request. The Plan says the
services were not authorized because the Facility is a non-network provider who does not
work with the member's health plan. The member was referred by a provider who also does not work
with the member's plan. The member's primary care physician (PCP) did not refer for services. The health plan
requires utilization of network providers when possible and available and requires authorization for certain
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has
been documented.
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 sterile water (A4216), supplies for maintenance of
non-insulin drug infusion catheter (A4221), infusion supplies for external drug infusion pump (A4222), an
injection of dobutamine hydrochloride (J1250), and an injection of heparin sodium (J1644) provided on August
21, 2019 to August 27, 2019 by the out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on August 20, 2019 by the out of network provider.
You asked the Plan to pay for lab services. You say that you are appealing the claim payment denial for services rendered to the Plan's member on date of service August 20, 2019. The Plan denied your request. The Plan says the rendering provider is a non-participating provider. The plan did not authorize any services for the provider, who is a non-participating provider. The services were not considered urgent/emergent in nature. There are multiple in-network providers within 30 miles of the member's residence that could have rendered the services.
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 laboratory services provided on August 20, 2019 by out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says IRF admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the enrollee's medical status requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional therapy of physical therapy and occupational therapy, but the patient does not require this on an intensive rehabilitation facility therapy program level in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services.
You asked the Plan to pre-approve SNF services. You say that you are at risk for falls and have not reached any
of your goals. The Plan denied your request. The Plan says you are medically stable, and have not had a change
in function where you require daily skilled therapy services.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above are met. Custodial care is 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 SNF services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found that from a nursing perspective, you
have stable vital signs, and your lungs are clear. There are no identifiable skilled nursing service needs.
Regarding rehab services, you are at a modified independent to contact guard assist level with functional
mobility. You require varying assist with activities of daily living. Although there are identifiable skilled
therapy service needs, you do not require skilled nursing or skilled therapy services on a daily 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 SNF services have not been met. Therefore, we decided that the Plan does not
have to pre-approve skilled nursing facility (SNF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services and office visits provided on July 15, 2019 to September 23, 2019 by out of network providers.
You asked the Plan to pay for these out-of-network services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received 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 laboratory services and office visits provided on July 15, 2019 to September 23, 2019 by out of network providers
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-one (J7325).
You asked the Plan to pre-approve Synvisc-one. You say that the requested medication is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria for a step therapy exception has not been met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Synvisc-one. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the documentation does not support that Orthovisc and Monovisc would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc-one have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc-one (J7325).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the oxygen services provided on August 29, 2019 by the out of network provider.
You asked the Plan to pay for the oxygen concentrator. You say that the enrollee wants to stay on service with the facility. The Plan denied your request. The Plan says there is no current documentation of medical necessity and you did not request prior authorization.
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 oxygen services provided on August 29, 2019 by the out of network provider.
Appeal type: Outpatient Therapies
Decision: Partially Favorable

We decided that the Plan has to pay for therapeutic activities (97530) provided on February 4, 2019. We decided that the Plan does not have to waive the copayment for physical therapy services provided on February 4, 2019 through February 19, 2019.
You asked the Plan to pay and waive the copayment for physical therapy services provided on February 4, 2019 through February 19, 2019. You say that you would like reconsideration based on the records submitted. The Plan says that the supporting documentation received does not support the billed code.
We decided that the Plan has to pay for the therapeutic activities (97530) provided on February 4, 2019.
The Plan follows Medicare rules. The rules say that Medicare plans must make reasonable and diligent efforts to gather and forward information to the Independent Review Entity (IRE).
The documentation submitted does not include medical records to substantiate the Plan's denial. Therefore, we decided that the Plan has to pay for the therapeutic activities (97530) provided on February 4, 2019.
We also decided that the Plan does not have to waive the copayment for physical therapy services provided on February 4, 2019 through February 19, 2019.
The Plan follows Medicare rules. The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles and coinsurance). The Plan contract clearly states that enrollees must pay $40 for PT services rendered in an outpatient hospital setting.
You have been asked to pay $200 for 5 PT visits. $40x5=$200. This is the correct copayment.
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 PT services provided on February 4, 2019 through February 19, 2019.
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadmission to a long term acute care hospital (LTACH) 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 services you need could be provided in another setting, such as an acute rehabilitation facility, skilled nursing facility, nursing facility, outpatient setting, or home 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 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. Initially admitted with shortness of breath, the enrollee was diagnosed with having had a NSTEMI, which was followed by an in-hospital stroke. The enrollee did not respond to neurologic interventions and is noted to have hemiplegia and dysphagia. A feeding tube has been placed. The enrollee is not intubated/ventilated. 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-approveadmission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections (64493, 64494 and 64495).
You asked the Plan to pre-approve the injections. You say that the injections are medically necessary. The Plan denied your request. The Plan says there is no record of a 6-week trial of physical therapy and no record of the member's response to the prior lumbar facet joint injection.
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 injections. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there are no physical examination findings such as facet joint tenderness or reproduction of pain with facet loading maneuvers or pattern of pain with range of motion that supports a diagnosis of facet mediated pain. There is also no adequate description in terms of degree and duration of pain relief as a result of the prior facet injections performed. 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 injections have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint injections (64493, 64494 and 64495).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ondansetron for the enrollee.
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 self-administered drugs are not covered.
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 ondansetron for the enrollee.
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.