Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for elbow orthosis (L3761) provided December 6, 2019.
You asked the Plan to pay for the orthosis. You say that please see the attached medical records which prove the medical necessity of the item and process the claim for payment. The Plan denied your request. The Plan says no medical records were received to support the diagnosis on the submitted order.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the orthosis have not been met. Therefore, we decided that the Plan does not have to pay for elbow orthosis (L3761) provided December 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for office visit services provided to the enrollee on January 9, 2020.You asked the Plan to pay for the services. You say that this should be paid for.The Plan denied your request. The Plan says the claim was processed correctly towards the deductible.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $198 deductible for covered medical services. The item or service you asked the Plan to pay for falls within the benefit category covered medical services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $198 deductible for covered medical services. This cost sharing is a contractual obligation that had not been met at the time the services was received on January 9, 2020.Therefore, we decided that the Plan does not have to pay for office visit services provided to the enrollee on January 9, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered from July 17, 2019 to July 19, 2019.You asked the Plan to pay for these services. You say that you disagree with the denial.The Plan denied your request. The Plan says the claims were not billed correctly.The Plan must follow Medicare rules. Medicare rules say that home health claims must be billed with a valid Q code, revenue code, and treatment authorization code.We looked at the file and Medicare rules. The claims were not billed with a valid Q code, revenue code, or treatment authorization code. 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 pay for the home health services rendered from July 17, 2019 to July 19, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an Ambulance Transport (A0428) provided June 12, 2019You asked the Plan to waive the copayment forthe Ambulance Transport. You say that the copayment should be waived.The Plan denied your request. The Plan says the correct copayment was applied.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 $90 copayment for Ambulance Services. You have been asked to pay a $90 copayment for the Ambulance Transport. The Ambulance Transport falls within the Ambulance Services 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 Ambulance Transport (A0428) provided June 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the oxygen concentrator provided on December 25, 2019 by an out of network (OON) provider.You asked the Plan to pay for the oxygen concentrator. The Plan denied your request. The Plan says that authorization was not provided for these 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 the oxygen concentrator provided on December 25, 2019 by an out of network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on December 27, 2019.
You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
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 did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for psychotherapy services provided on December 27, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve infuse NULOJIX IV.
You asked the Plan to pre-approve infuse NULOJIX IV. You say that you want the enrollee treated with this drug. The Plan denied your request. The Plan says the drug will be used in combination with other drugs and cannot be administered in the home setting.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve infuse NULOJIX IV. Our reviewer says that this drug is not safe for the enrollee. Our physician reviewer found the provided medical records do support that the NULOJIX is medically reasonable and necessary for the patient. The provided medical records do not support that the NULOJIX is safe and effective for the enrollee to receive in the home setting. Patients receiving the drug should be managed in facilities equipped and staffed with adequate laboratory and supportive medical resources. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of infuse NULOJIX IV have not been met. Therefore, we decided that the Plan does not have to pre-approve infuse NULOJIX IV.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tramadol HCL Tab.
You asked the Plan to pre-approve Tramadol HCL Tab. You say that the enrollee has tried previous medications but they don't work. The Plan denied your request. The Plan says this is a Part D drug not covered under this plan.
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 Tramadol HCL Tab.
Benefits for Tramadol HCL Tab 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a shoulder-hand-wrist orthosis (L3960) provided to the enrollee on November 18, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for a shoulder-hand-wrist orthosis (L3960) provided to the enrollee on November 18, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for services provided on February 7, 2018.
You asked the Plan to pay for the ambulance services. You say that the claim was timely. The Plan denied your
request. The Plan says the claim was untimely.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010
must be filed no later than one calendar year after the date of service.
The record shows that a claim for the ambulance services was not filed until May 13, 2019. This means that
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we
decided that the Plan does not have to pay for services provided on February 7, 2018.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four monitoring (95937) provided on July 10, 2019.You asked the Plan to pay for the train of four monitoring. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the documentation indicates that train of four testing/monitoring was performed which does not meet the CMS guidelines of CPT code 95937.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 95937 is neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method.We find that CPT code 95937 is not supported in the record. Specifically, train of four monitoring does not meet the CMS definition of CPT code 95937. Based on this information, we decided that Medicare rules for coverage of the train of four monitoring have not been met.Therefore, we decided that the Plan does not have to pay for train of four monitoring (95937) provided on July 10, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on January 14,
2020.
You asked the Plan to waive the copayment for a specialist visit. You say that you thought the first 5 visits
would be covered without a copayment. 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 $20
copayment for specialist visits.
You have been asked to pay a $20 copayment for a specialist visit. A specialist visit falls within the
physician/practitioner services, including doctor's 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 visit provided on January 14, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services coded 99153 and the x-ray services coded 73600 provided on March 6, 2019.
You asked the Plan to pay for the moderate sedation services and the x-ray services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 99153 is Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List separately in addition to code for primary service). In this case, the CPT Code Manual definition of code 73600 is Radiologic examination, ankle; 2 views. We find that CPT codes 99153 and 73600 are not supported in the medical record. Specifically, the documentation submitted and the claim form indicate that this procedure was performed in a facility place of service of 23. Payment for this service is included in payment to the facility and not separately reimbursable for this provider in this place of service.
Also, code 73600 is included in CPT code 73610 that was already processed and paid by the plan. Based on this information, we decided that Medicare rules for coverage of the moderate sedation services and the x-ray services have not been met. Therefore, we decided that the Plan does not have to pay for the moderate sedation services coded 99153 and the x-ray services coded 73600 provided on March 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on June 12, 2019 by an out of network (OON) provider.You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says there are in-network doctors available for these 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 physician services provided on June 12, 2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the contrast material provided on April 16, 2018.
You asked the Plan to waive the coinsurance for the contrast material. You say that it was originally covered in full. You say that you shouldn't be liable for the coinsurance. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for Medicare-covered supplies. You have been asked to pay $1.68, which is 20% of the allowed amount for the contrast material. The allowed amount is $8.40 (20% x $8.40 = $1.68). The contrast material falls within the "Outpatient hospital services" 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 coinsurance for the contrast material provided on April 16, 2018.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the emergency room visit, the initial observation care, or the specialist office visit provided from December 22, 2019 to January 9, 2020.You asked the Plan to waive the cost share for the emergency room visit, the initial observation care; and the specialist office visit. You say that this bill is too high and you do not have a lot of moneyThe 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 $90 copayment for each separate Medicare-covered emergency room visit, 20% of the cost for Medicare-covered outpatient hospital surgery and other services, a $45 copayment for each Medicare-covered specialist visit. You have been asked to pay total of $176.40 for the emergency room visit, the initial observation care, and the specialist office visits. The emergency room visit falls within the "Emergency care" benefit category. The initial observation care falls within the "Outpatient hospital services" benefit category. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. See chart below.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the comprehensive hearing test provided on August 20, 2019.
You asked the Plan to waive the copayment for the comprehensive hearing test. You say that the hearing exam should be included in the copayment for the specialist visit. 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 $20 copayment for each in-network, Medicare-covered hearing exam to determine if you need medical treatment for a hearing condition.
You have been asked to pay a $20 copayment for the comprehensive hearing test. The comprehensive hearing test falls within the "Hearing services - Medicare-covered" 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 the comprehensive hearing test provided on August 20, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomographic colonography (CTC) screening you received on December 30, 2019.
You asked the Plan to pay for the CT screening. You say that the testing was recommended by your doctor. The Plan denied your request. The Plan says the testing is not covered by Medicare.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal, the CT screening, was requested for screening purposes. Medicare does not cover this test for screening purposes. There is no documentation that the test at issue was authorized prior to the services being provided. Therefore, we decided that the Plan does not have to pay for the computed tomographic colonography (CTC) screening you received on December 30, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on January 3, 2020.
You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says services provided by non-contract providers are not covered unless pre-authorized.
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 did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for psychotherapy services provided on January 3, 2020.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to waive the coinsurance for hyperbaric oxygen therapy provided on January 2,
2020.
You asked the Plan to waive the coinsurance for hyperbaric oxygen therapy. You say that you should not owe
anything for the services. The Plan denied your request. The Plan says that 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 does not say in clear and accurate terms
how much you should expect to pay for outpatient diagnostic tests and therapeutic services and supplies.
We looked at your contract with the Plan. We did not see where the contract says enrollees must pay 20%
coinsurance for hyperbaric oxygen therapy. The Plan contract does not clearly say how much enrollees must
pay for outpatient therapeutic services. This means that the Plan did not follow Medicare rules for disclosure of
cost sharing information. Therefore, we decided that the Plan has to waive the coinsurance for hyperbaric
oxygen therapy provided on January 2, 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.