Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from October 1, 2019 through October 7, 2019.You asked the Plan to waive the copayment for inpatient hospital care. You say that you were assessed two different inpatient copayments for admissions to two different hospitals, pertaining to the same procedure.The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file shows that you received inpatient hospital care from October 1, 2019 through October 7, 2019. You were asked to pay a $425 copayment for your inpatient hospital care. Per your contract there is a $425 copayment per admission. 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 inpatient hospital care provided from October 1, 2019 through October 7, 2019.
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 7, 2019 to July 11, 2019.You asked the Plan to pay for home health 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 missing required information.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, home health claims require the appropriate home health data. The claim was not submitted with the required Q code. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from July 7, 2019 to July 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forknee orthosis (L1851), shoulder elbow wrist hand orthosis (L3960) and suspension sleeve (L2397) provided to the enrollee on June 7, 2019.You asked the Plan to pay for the orthoses and sleeve. You say that the durable medical equipment is medically necessary.The Plan denied your request. The Plan says the documentation indicates services are not necessary for treatment of the enrollee's condition.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine ifthe Plan was correct in denying the request to pay for the orthoses and sleeve. Our reviewer says that the enrollee does not meet criteria for the orthoses and sleeve ordered. Our physician reviewer found the documentation in the case file does not support that the requested knee orthosis and sleeve were medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. There is no documentation of recent injury to, or recent surgical procedure on, the enrollee's knee, and there is insufficient credible objective documentation of joint laxity. The item coded L2397 (sleeve) is not separately payable when the base item is not covered. The documentation in the case file does not support that the requested shoulder/arm orthosis was medically reasonable and necessary for the enrollee in this case. A 
physical examination of the shoulder would reasonably be required to adequately assess whether the shoulder/arm orthosis was medically necessary for an enrollee. The documentation does not support that the orthosis was medically reasonable and necessary for the enrollee in this case, as there is insufficient documentation of a credible physical examination of the shoulder. 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 orthoses and sleeve have not been met.Therefore, we decided that the Plan does not have to pay for knee orthosis (L1851), shoulder elbow wrist hand orthosis (L3960) and suspension sleeve (L2397) provided to the enrollee on June 7, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forwrist hand orthosis (L3908) provided to the enrollee on August 23, 2019.You asked the Plan to pay for the orthosis. You say that the durable medical equipment is medically necessary.The Plan denied your request. The Plan says medical records and claim history indicate this item was dispensed in a facility setting.The Plan must follow Medicare rules. 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. Healthcare Common Procedure Coding System (HCPCS) code L3908 LT remains not supported. Medical records and claim history indicate this item was dispensed in a facility setting 24; therefore, this code is included in the payment of the other services performed on the same date of service, for the same patient, and by the same provider and is not separately reimbursable. In addition, the medical records submitted do not include a valid physician order with the order date and start date.Therefore, we decided that the Plan does not have to pay for wrist hand orthosis (L3908) provided to the enrollee on August 23, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for progressive lenses and anti-reflective coating provided on October 9, 2019.You asked the Plan to reimburse you the progressive lenses and anti-reflective coating. The Plan denied your request. The Plan says only routine eyeglasses are a covered vision benefit.Medicare rules say that progressive lenses will be denied as non-covered. Medicare rules say that that anti-reflective coating are covered only when they are medically necessary for the individual beneficiary and the medical necessity is documented by the treating physician. When these features are provided as a beneficiary preference item and are billed with an EY modifier they will be denied as not reasonable and necessary.
We looked at the file and Medicare's rules. Medicare says progressive lenses are non-covered. Medicare only covers anti-reflective coating when documented by the treating physician as medically necessary. The file does not contain documentation from the treating physician to substantiate Medicare's coverage criteria for the anti-reflective coating.Therefore, we decided that the Plan does not have to reimburse you for progressive lenses and anti-reflective coating provided on October 9, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthosis (L1851) and suspension sleeve (L2397) provided to the enrollee on July 11, 2019.You asked the Plan to pay for the orthoses and sleeves. You say that the durable medical equipment is medically necessary.The Plan denied your request. The Plan says they were unable to discover any evidence of an established relationship between the member and the ordering physician. The Plan states there were no claims submitted for an evaluation and management service. The Plan states the review of claims history for this member, and a review of the submitted documentation does not contain evidence of a prior Telemedicine or Telehealth service with the ordering physician as required per CMS guidelines.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 knee orthosis (L1851) and suspension sleeve (L2397) provided to the enrollee on July 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forknee orthosis (L1851) and suspension sleeve (L2397) provided to the enrollee on July 10, 2019.You asked the Plan to pay forthe orthosis and sleeve. You say that the durable medical equipment is medically necessary.The Plan denied your request. The Plan says they were unable to discover any evidence of an established relationship between the member and the ordering physician. The Plan states there were no claims submitted for an evaluation and management service. The Plan states the review of claims history for this member, and a review of the submitted documentation does not containevidence of a prior Telemedicine or Telehealth service with the ordering physician as requiredper CMS guidelines.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 forknee orthosis (L1851) and suspension sleeve (L2397) provided to the enrollee on July 10, 2019
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (80061, 85048, 82247, 82947) provided on August 23, 2019 by out of network provider. You asked the Plan to pay for laboratory services. You say that you are requesting the denial be reconsidered for payment as the services were medically reasonable and necessary. The Plan denied your request. The Plan says the referring provider is a non-participating provider. The plan did not authorize any services for provider or referring provider. There are multiple in-network providers within 30 miles of the member's residence that could have rendered the services. The services are not considered urgent/emergent in nature. 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 (80061, 85048, 82247, 82947) provided on August 23, 2019 by out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on August 28, 2019.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 Healthcare Common Procedure Coding System (HCPCS) G0482 (1 Unit) remains not supported.The Plan must follow Medicare rules. Medicare rules say that a physician order must be present for labs to be covered.The documentation submitted did not include a physician order/lab requisition or medical records stating exactly tests were 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 drug testing services provided to the enrollee on August 28, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the laboratory services rendered to you on July 15, 2019.You asked the Plan to waive the deductible for these services. You say that you would like the claim processed in-network.The Plan denied your request. The Plan says the deductible was applied correctly.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 $750 yearly deductible for your covered medical services. The item or service you asked the Plan to waive the deductible for falls within the out-of-network laboratory services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $750 yearly deductible for your covered medical services. This cost sharing is a contractual obligation that had not been met at the time these services were received on July 15, 2019. Therefore, we decided that the Plan does not have to waive the deductible for the laboratory services rendered to you on July 15, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and the prophylaxis (D1110) provided on May 6, 2019.You asked the Plan to pay for the dental services. You say that You say that you contacted the provider's office to make sure the services were plan approved.The Plan denied your request. The Plan says The Plan says they confirmed with the provider's office that the dentist you received services from has opted out of Medicare. The Plan also says they are unable to make any payment on services that were received by a provider that has opted out of Medicare.The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.The services at issue in this appeal were provided in a non-urgent,non-emergent situation by the provider. This provider has opted out of the Medicare program. The file shows that the provider entered into a private contract with you regarding payment.Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and the prophylaxis (D1110) provided on May 6, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from October 7, 2019 through October 17, 2019.You asked the Plan to waive the copayment for inpatient hospital care. You say that the admission was a continuation of your inpatient acute care admission from October 1, 2019 through October 7, 2019.The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). You were admitted to inpatient acute care on October 1, 2019 and discharged on October 7, 2019. You were then admitted to inpatient rehabilitation later that day. Therefore, you are asked to pay a $425 copayment for the inpatient hospital care. Per your contract there is a $425 copayment per admission. 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 inpatient hospital care provided from October 7, 2019 through October 17, 2019.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the services provided to enrollee on January 29, 2019.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the billed services were fraudulent.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The plan contends that the billed services were misrepresented, and that the documentation indicates that fraud and abuse has been committed. While there may be evidence of fraudulent billing in this case, the plan has not clearly pointed to any evidence supporting its denial. Therefore, we decided that the Plan has to pay for the services provided to enrollee on January 29, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99215) provided on August 27, 2019 by out of network provider.You asked the Plan to pay for an office visit. You say that the treatment was medically necessary as to not compromise the patient's health and well-being and does concur with the Plan's current policy.The Plan denied your request. The Plan says the attending provider is a non-participating provider. The plan did not authorize any services for the practice or the provider. The services are not considered urgent/emergent in nature. There was no referral for an out-of-network provider. There are in-network providers available within a reasonable distance to the member that could have performed the requested service. Services rendered by non-participating providers, require prior authorization as outlined in the enrollee's EOC.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 foran office visit (99215) provided on August 27, 2019 by out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing coded 80307 and G0483 provided on July 30, 2019.You asked the Plan to pay for the drug testing. 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.We find that CPT codes 80307 and G0483 are not supported in the medical record. Specifically, the documentation submitted did not include a valid physician order/lab requisition or medical records (signed by the ordering physician) stating exactly what tests were to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met.Therefore, we decided that the Plan does not have to pay for the drug testing coded 80307 and G0483 provided on July 30, 2019
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services on March 15, 2019.You asked the Plan to waive the copayment for ambulance services. You say that you were forced in an ambulance against your will.The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received ambulance services on March 15, 2019. You are asked to pay a $180 copayment for the ambulance services. 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 ambulance services on March 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on March 14, 2019 by the out of network provider.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 services were rendered by a non-contracted provider without 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 medical services provided on March 14, 2019 by the out of network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on September 6, 2019.You asked the Plan to pay for the pump assembly and operation. You say that it takes a half hour to an hour to set up the Heart Lung Machine and the perfusionist is required to be in the operating room during the length of the procedure. The Plan denied your request. The Plan says payment for this service would be included in the part-A DRG payment to the facility.The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the pump assembly and operation have not been met. Specifically, payment for this service is included in the DRG payment to the facility. Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on September 6, 2019.