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

We decided that the Plan does not have to pay for the shoulder/arm orthosis provided to the enrollee on February 28, 2019.
You asked the Plan to pay for the orthosis. You say that this was medically necessary. The Plan denied your request. The Plan says that they were unable to discover any evidence of an established relationship between the member and the ordering physician.
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 the shoulder/arm orthosis provided to the enrollee on February 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided to the enrollee on June 11, 2019.
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your request. The Plan says physical therapy modalities, X-rays, rehabilitation and other incidental services including office evaluation and management by chiropractors are not covered by Medicare.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for chiropractic services provided to the enrollee i on June 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe orthotics management and training, upper extremity, lower extremity and/or trunk, initial orthotic encounter, each 15 minutes provided by the provider on May 28, 2019.You asked the Plan to pay forthe orthotics management and training. You say that you are requesting reconsideration based on medical necessity for this enrollee and evidence based medical literature that substantiate the efficacy of the treatment rendered.The Plan denied your request. The Plan says the records do not support the services billed.The Plan must follow Medicare rules. Medicare rules say that therapy services must be billed with HCPCS codes with the appropriate modifier.  The claim must include one of the following modifiers to distinguish the discipline of the plan of care under which the service is delivered: GN Services delivered under an outpatient speech-language pathology plan of care; GO Services delivered under an outpatient occupational therapy plan of care; or, GP Services delivered under an outpatient physical therapy plan of care.Based on this information, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay forthe orthotics management and training, upper extremity, lower extremity and/or trunk, initial orthotic encounter, each 15 minutes provided on May 28, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for test strips (A4253), lancets (A4259), calibrator solution
(A4256), and batteries (A4235) provided on July 23, 2019 to October 11, 2019.
You asked the Plan to pay for test strips, lancets, calibrator solution, and batteries. You say that these items
should be covered. The Plan denied your request. The Plan says the delivery ticket submitted did not include
the carrier's tracking number, nor did the proof of delivery include an order number or details to corroborate the
delivery ticket.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a
physician order and proof of delivery.
The record shows that the Plan made several attempts to obtain the physician order and proof of delivery
documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the
supplies provided in this case. Specifically, the delivery ticket and the proof of delivery did not corroborate one
another in regards to an order number and carrier. Therefore, we decided that the Plan does not have to pay for
test strips (A4253), lancets (A4259), calibrator solution (A4256), and batteries (A4235) provided on July 23,
2019 to October 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the diabetic supplies rendered to the enrollee by the provider on May 16, 2019 to August 4, 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 there is no valid proof of delivery.
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS suppliers are required to maintain proof of delivery. We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. 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 diabetic supplies rendered to the enrollee by the provider on May 16, 2019 to August 4, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for lancets (A4259), calibrator solution / chips (A4256), blood glucose test or reagent strips for home blood glucose monitor (A4253), and lithium battery (A4235) provided from August 13, 2019 to November 1, 2019 by the provider.
You asked the Plan to pay for lancets, calibrator solution / chips, blood glucose test or reagent strips, and lithium battery. You say that the items were provided and payment should be rendered. The Plan denied your request. The Plan says the documentation provided did not include a valid proof of delivery. Therefore, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the physician order and proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. Specifically, the delivery ticket is missing a valid signature. Therefore, we decided that the Plan does not have to pay for lancets (A4259), calibrator solution / chips (A4256), blood glucose test or reagent strips for home blood glucose monitor (A4253), and lithium battery (A4235) provided from August 13, 2019 to November 1, 2019 by the provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the diabetic supplies rendered to the enrollee by the practice from August 8, 2019 to October 27, 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 there is no valid proof of delivery. 
The Plan must follow Medicare rules. The rules say that all DMEPOS suppliers are required to maintain proof of delivery. We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. 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 diabetic supplies rendered to the enrollee by the practice from August 8, 2019 to October 27, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the wrist/hand orthosis (L3916) provided by the practice on April 18, 2019.
You asked the Plan to pay for the orthosis. You say that the records provided should support the necessity of the services in dispute. The Plan denied your request. The Plan says evidence of misrepresented services.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain an itemized shipping/billing invoice for the items at issue in this appeal. In addition, no documentation was received to support the diagnosis on the submitted order. Therefore, we decided that the Plan does not have to pay for the wrist/hand orthosis (L3916) provided by the practice on April 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for outpatient hospital visit provided by the Hospital on July 2, 2019 to July 23, 2019.
You asked the Plan to waive the coinsurance for outpatient hospital visit. You say that this could have been done at your doctor's office and it would have cost you $0. The Plan denied your request. The Plan says the correct coinsurance has been 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 20% coinsurance for outpatient hospital services/nonsurgical visit. You have been asked to pay a 20% coinsurance of the allowed amount for outpatient hospital visit. The allowed amount is $535. The total amount you are being asked to pay is $107 ($535 x 20% = $107). Outpatient hospital visit falls within the outpatient hospital services/nonsurgical visit 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 outpatient hospital visit provided by the Hospital on July 2, 2019 to July 23, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation provided and the sinus augmentation with bone or bone substitutes, bone replacement graft for ridge preservation, apicoectomy, and the 2 problem focused limited oral evaluations provided.
You asked the Plan to pay for the dental services. You say that you paid for additional insurance coverage so you could get bridges, implants, and several other procedures over a period of time. The Plan denied your request. The Plan says you did not have an active plan during the time the services were provided. The Plan also confirmed that you were only enrolled in the MyOption Dental (PPO).
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation provided and the sinus augmentation with bone or bone substitutes, bone replacement graft for ridge preservation, apicoectomy, and the 2 problem focused limited oral evaluations provided.
Your complaint about being cheated by the insurance Plan is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for the non-emergent ambulance services provided to the enrollee on August 16, 2019.
You asked the Plan to pay for the non-emergent ambulance services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the services rendered were not medically necessary.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 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 non-emergent ambulance services. Our reviewer says that the documentation supports that the Our physician reviewer found the enrollee was evaluated at the emergency department for chest pain. Following evaluation, the enrollee was transported back to his living facility by ambulance. The enrollee was maintained on oxygen and required two person lift for transfer. The documentation states the enrollee has bilateral lower extremity amputation. Transportation by ambulance is supported by the records as medically necessary. 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 non-emergent ambulance services have been met. Therefore, we decided that the Plan has to pay for the non-emergent ambulance services provided to the enrollee on August 16, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe diabetic testing supplies provided to the enrollee from August 4, 2019 to October 23, 2019.You asked the Plan to pay forthe provided supplies. The Plan denied your request. The Plan says the proof of delivery does not corroborate with the delivery ticket.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain valid proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. Therefore, we decided that the Plan does not have to pay forthe diabetic testing supplies provided from August 4, 2019 to October 23, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Monovisc injection provided on July 30, 2019.You asked the Plan to waive the coinsurance for the Monovisc injection. You say that you were not informed there was going to be a copayment balance. You say that you are unable to pay.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 Part B chemotherapy drugs and other Part B drugs.You have been asked to pay $604.46, which is 20% of the allowed amount for the Monovisc injection. The allowed amount is $3,022.29 (20% x $3,022.29 = $604.46).The Monovisc injection falls within the "Medicare Part B prescription drugs" 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 Monovisc injection provided on July 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the end stage renal disease (ESRD) related services monthly, for 4 months, provided on June 30, 2019 by the out of network provider.You asked the Plan to pay forthe physician services. You say that you have been providing this service to the enrollee for years and it has been covered. You say that it is the dialysis center's responsibility to request authorization. You also say that you were not aware that the services were not approved this time.The Plan denied your request. The Plan says authorization was not obtained before the services were provided to the enrollee.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 provider in this case is not a network provider with the Plan. 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 forthe end stage renal disease (ESRD) related services monthly, for 4 months, provided on June 30, 2019 by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe office visit provided on July 15, 2019.You asked the Plan to waive the copayment forthe office visit. You say that you were informed that the second visit was a follow up. You say that you are appealing the second $50 charge.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 $50 for each Medicare-covered visit with an in-network specialist. You have been asked to pay a $50 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show that you were examined, treatment options were discussed and an x-ray was performed during the office visit. 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 office visit provided on July 15, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora CT scan provided at the medical center on July 8, 2019.You asked the Plan to waive the copayment fora CT scan. You say that you disagree with the charges.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 planmust 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 diagnostic radiology services up to $75 per day. You have been asked to pay $75 for a CT scan, which is less than the coinsurance amount. A CT scan 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 fora CT scan provided on July 8, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that the Plan should reprocess the claim for payment. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on July 9, 2019 by the out of network provider.
You asked the Plan to pay for the physician services. The Plan denied your request. The Plan says authorization was not obtained before the services were provided to the enrollee. The Plan also says the services were not urgent or emergent.
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 provider in this case is not a network provider with the Plan. The facility is not a network provider either. 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 office visit provided on July 9, 2019 by the out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the blood glucose (BG) monitor (E2100) BG test/reagent strips (A4253) lancets (A4259) calibrator solution/chips (A4256) and spring powered device for lancet (A4258) provided by the practice on July 15, 2019 to October 3, 2019.
You asked the Plan to pay for the diabetic supplies. You say that the records provided should support the necessity of the services in dispute. The Plan denied your request. The Plan says evidence of misrepresented services.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case and the deliver ticket submitted did not include the carrier's tracking number. Therefore, we decided that the Plan does not have to pay for the blood glucose (BG) monitor (E2100) BG test/reagent strips (A4253) lancets (A4259) calibrator solution/chips (A4256) and spring powered device for lancet (A4258) provided by the practice on July 15, 2019 to October 3, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for an abdomen x-ray (74018-26-77) provided on July 10, 2019 by the provider.
You asked the Plan to pay for the abdomen x-ray. You say that the service was provided and payment should be rendered. The Plan denied your request. The Plan says the billed code is a duplicate claim line. Based on Medicare billing criteria, duplicate claims are not eligible for payment.
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 74018-26-77 is an abdomen x-ray. We find that CPT code 74018-26-77 is not supported in the medical record. Specifically, each claim was billed as 74018-26-77 which is duplicate billing. Code 74018-26-77 was already paid by the plan. Based on this information, we decided that Medicare rules for coverage of the abdomen x-ray have not been met. Therefore, we decided that the Plan does not have to pay for an abdomen x-ray (74018-26-77) provided on July 10, 2019 by the provider.