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

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) and a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on December 6, 2019. You asked the Plan to pay for the orthoses. 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 lumbar-sacral orthosis (L0650) and a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on December 6, 2019.
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 March 1, 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. The rules state that DMEPOS is covered only when the patient's medical
record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the
type and quantity of items ordered and for the frequency of use.
The record shows that documentation submitted did not indicate the provider discussed the need for the billed
supply code, so the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to
pay for a shoulder-hand-wrist orthosis (L3960) provided to the enrollee on March 1, 2019.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pre-approve home health physical and occupational therapy visits for the enrollee.You asked the Plan to pre-approve home health services. You say that this is medically necessary.The Plan denied your request. The Plan says that this is not medically necessary.The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.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 home health services. Our reviewer says that the requested visits are medically reasonable and necessary. Our physician reviewer found physical and occupational therapy services are considered specific and effective for treating impairments of mobility and activities of daily living after hospitalization. As of the dates in question the enrollee continued to require hands-on assistance for essential activities of daily living such as transfers. There is no evidence that shehad reached a functional plateau with the therapy services that had been provided. She remained homebound as she was unable to leave her residence due to stair negotiation. The enrollee was appropriately discharged after meeting her goals. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health services have been met.Therefore, we decided that the Plan has to pre-approve home health physical and occupational therapy visits for the enrollee.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 the medical services provided on October 29, 2019 by an out of network (OON) provider. You asked the Plan to pay for the OON services. You say that it was beyond your ability to obtain the authorization. The Plan denied your request. The Plan says a prior authorization was not requested or provided for this service.
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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these OON services. Therefore, we decided that the Plan does not have to pay for the medical services provided on October 29, 2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the MRI provided on October 5, 2019. You asked the Plan to waive the copayment for the MRI. You say that if your doctor didn't recommend the MRI, you would have continued suffering from pain. You say that the Plan should cover the 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 $300 for Medicare covered advanced imaging or nuclear medicine services in a physician office or outpatient facility setting, in addition to any applicable office visit or facility copayment. You have been asked to pay a $300 copayment for the MRI. The MRI falls within the "Outpatient diagnostic tests and therapeutic services and supplies" 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 MRI provided on October 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a follow-up office visits and debridement provided on August 7, 2019 by an out of network (OON) provider.
You asked the Plan to pay for a follow-up office visits and debridement. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained.
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 a follow-up office visits and debridement provided on August 7, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthoses and suspension sleeves provided on December 2, 2019.You asked the Plan to pay for the knee orthoses (L1833) and suspension sleeves (L2397). You say that the Plan should pay this claim.The Plan denied your request. The Plan says the documentation submitted did not indicate the provider discussed the need for the billed supply codes, therefore the billed supply codes cannot be verified.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. The medical records do not support medical necessity for the orthoses. Based on this information, we decided that Medicare rules for coverage of the knee orthosis (L1833) and suspension sleeve (L2397) have not been met.Therefore, we decided that the Plan does not have to pay for the knee orthoses and suspension sleeves provided on December 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on November 14, 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 procedure codes 31628, 31624, 31632, and 99152 are not supported.
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 31628 is bronchoscopy, rigid or flexible, including
fluoroscopic guidance, when performed; with transbronchial lung biopsy(s), single lobe. The definition of code
31624 is bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial
alveolar lavage. The definition of code 31632 is bronchoscopy, rigid or flexible, including fluoroscopic
guidance, when performed; with transbronchial lung biopsy(s), each additional lobe (List separately in addition
to code for primary procedure). The definition of code 99152 is moderate sedation services by physician also
performing a procedure, patient 5 years of age or older, first 15 minutes.
We find that CPT codes 31628, 31624, 31632, and 99152 are not supported in the medical record. Specifically,
the records do not contain documentation that a bronchoscopy, rigid or flexible, with fluoroscopic guidance
with transbronchial lung biopsy was performed to support code 31628. The records do not support that
bronchoscopy with bronchial alveolar lavage was performed to support code 31624. Code 31632 is an add-on
code and given that the primary code of 31628 is not supported, the add-on code is also not supported. The
records do not include documentation of an independent trained observer to assist in monitoring the patient's
level of consciousness and physiological status to support code 99152.
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 surgical services rendered on November 14,
2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic digital breast tomosynthesis (77062) provided on
December 27, 2019.
You asked the Plan to pay for the diagnostic digital breast tomosynthesis. You say that you would like
reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code 77062
has a status code of I which is not valid for Medicare purposes.
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 77062 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT
code 77062 has a status code of I. This means that CPT code 77062 is not valid for Medicare purposes. Based
on this information, we decided that Medicare rules for coverage of the diagnostic digital breast tomosynthesis
have not been met. Therefore, we decided that the Plan does not have to pay for diagnostic digital breast
tomosynthesis (77062) provided on December 27, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on August 29, 2019.
You asked the Plan to waive the copayment for laboratory services. You say that you went for a wellness check but were billed for labs without your knowledge. You say that you shouldn't have incurred a bill. 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 lab services at an in-network outpatient hospital. You have been asked to pay a $40 copayment for laboratory services. Laboratory services fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. Outpatient diagnostic tests are considered a separate service. 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 laboratory services provided on August 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the SNF stay provided from November 8, 2019 to November 30, 2019.You asked the Plan to waive the copayment for the SNF stay. You say that due to your severe injuries, insurance should pay for your 30 days at the skilled nursing facility without you paying the copayment.The 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 $0 copayment per day, days 1 to 20 at an in-network skilled nursing facility and a $172 copayment per day, days 21 to 60 at an in-network skilled nursing facility. You have been asked to pay a $516 copayment for the SNF stay. The SNF stay falls within the "Skilled nursing facility (SNF) care" 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 SNF stay provided from November 8, 2019 to November 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a diagnostic or therapeutic injection (64495) provided on January 11, 2019.
You asked the Plan to pay for the injection. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says HCPCS code 64495 exceeds the allowable units of service for the same date of service.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied. In this case, the MUE for CPT code 64495 is 1. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the injection have not been met. Therefore, we decided that the Plan does not have to pay for a diagnostic or therapeutic injection (64495) provided on January 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided on October 9, 2019 by an out of network (OON) provider.
You asked the Plan to pay for skilled nursing services. You say that since the member is in a nursing facility, the doctor is not responsible to get authorization. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the referring facility is also out-of-network.
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 skilled nursing services provided on October 9, 2019 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe skilled nursing facility (SNF) services provided October 9, 2019 through October 20, 2019.You asked the Plan to pay forthe SNF services. You say that you feel that the plan should cover for SNF services.The Plan denied your request. The Plan says medical necessity cannot be established for SNF level of coverage.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 pay for the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing and skilled therapyservice needs. The enrollee does not require skilled nursing or therapy services on a daily basis and does not meet severity of illness or intensity of service criteria for 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 that Medicare rules for coverage of the SNF services have not been met.Therefore, we decided that the Plan does not have to pay forthe skilled nursing facility (SNF) services provided October 9, 2019 through October 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe treatment room provided on September 23, 2019.You asked the Plan to waive the copayment forthe treatment room. You say that you received a bill for a treatment room and you say you did not have any labs done. The 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 $325 copayment for Medicare-covered outpatient hospital services and observation services. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $325 copayment for treatment room.You have been asked to pay a $87.04 copayment for the treatment room. The treatment room falls within the "Outpatient hospital services" benefit category. The record shows you were only charged for the treatment room.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 forthe treatment room provided on September 23, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory testing provided on July 30, 2019.
You asked the Plan to pay for the laboratory testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.
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 laboratory testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory testing provided on July 30, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a joint injection provided on February 3, 2020.
You asked the Plan to waive the copayment for a joint injection. You say that you received a cortisone injection during a post-operative visit and disagree with the way the service was billed. 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 $250 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You received a joint injection on February 3, 2020 during a post-operative visit. Joint injections are considered outpatient surgical procedures and are subject to cost-sharing charges. Therefore, you are responsible to pay the $250 copayment. You have been asked to pay a $250 copayment for a joint injection. A joint injection 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 copayment for a joint injection provided on February 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on
October 7, 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 enrollee has previously received the same supplies within the 5-year RUL.
The plan must follow Medicare rules. Medicare rules say that the reasonable useful lifetime of durable
medical equipment is no less than five years. Replacement equipment may be granted when irreparable wear or
irreparable damage is demonstrated or there has been a change in the enrollee's medical condition.
We looked at the file and Medicare rules. In this instance, the submitted documentation indicates that the
enrollee has received the same durable medical equipment on January 25, 2019.
This orthosis is still within the 5-year RUL and the documentation submitted does not show that the orthosis is
irreparably worn, irreparably damaged, or that the enrollee had a change in medical condition to warrant the
orthosis at issue. 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 a lumbar-sacral orthosis (L0650)
provided to the enrollee on October 7, 2019.