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

We decided that the Plan does not have to waive the copayment foran X-ray of the wrist provided July 12, 2019 .You asked the Plan to waive the copayment forthe X-ray. You say that you say the copayment should be waivedThePlan 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 $35 copayment for X-rays. You have been asked to pay a $35 copayment for the X-ray. 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 foran X-ray of the wrist provided July 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the prolonged evaluation and management service coded 99358 provided.
You asked the Plan to pay for the prolonged evaluation and management service. 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 99358 is Prolonged evaluation and management service before and/or after direct patient care; first hour. We find that CPT code 99358 is not supported in the medical record. Specifically, the documentation provided does not show to be more than 30 minutes of prolonged care to support payment of this code. Based on this information, we decided that Medicare rules for coverage of the prolonged evaluation and management service have not been met. Therefore, we decided that the Plan does not have to pay for the prolonged evaluation and management service coded 99358 provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided by out of network provider.
You asked the Plan to pay for psychiatric services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says there was no prior authorization obtained prior to the services in question.
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 by out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on June 17, 2019 by the out of
network provider.
You asked the Plan to pay for the laboratory 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 a covered benefit.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on June 17, 2019
by an out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0483 provided to the enrollee.
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. In this case, the CPT Code Manual definition of code G0483 is Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed. We find that CPT code G0483 is not supported in the medical record. Specifically, the documentation does not include definitive laboratory results for 22 or more drug classes. 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 G0483 provided to the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the blood draw, and laboratory testing provided on June 28, 2019 by the out of network provider.You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says authorization was not obtained before the services were provided to the enrollee. The Plan says the enrollee was referred by another out of network provider. The Plan also says that there are in network providers that can provide 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 provider in this case is not a network provider with the Plan. The referring provider is not a network provider either. 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 blood draw, and laboratory testing provided on June 28, 2019 by the out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 3, 2019 by 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-network 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 referring provider 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 July 3, 2019 by out of network provide.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on July 16, 2019.You asked the Plan to pay forthe 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 arelikewise noncovered.Therefore, we decided that the Plan does not have to pay fora knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on July 16, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forscreening lab services provided to the enrollee on May 21, 2019.You asked the Plan to pay forthis service. You say that this claim should be paid. The Plan denied your request. The Plan says screening tests are 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. Thetest at issue in this appeal, this service, 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 forscreening lab services provided to the enrollee on May 21, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee from July 19, 2019 to July 31, 2019.You asked the Plan to pay for this service. You say that this claim should be paid.The Plan denied your request. The Plan says based on the Medicare guidelines, the plan is upholding the claim as the provider did not include this Treatment Authorization Code (TAC) required on Medicare claims. As this TAC code is required on HH PPS claims and was not included, he claim cannot be paid. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, the claim submitted is lacking the required TAC code and cannot be paid. Therefore, we decided that the Plan does not have to pay for home health services provided to the enrollee from July 19, 2019 to July 31, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on May 18, 2019 by an out of network provider.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services were rendered by a non-network 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 referring provider 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 forthe medical services provided on May 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for blood glucose test or reagent strips for home blood glucose monitor (A4253), lancets (A4259), calibrator solution / chips (A4256), and lithium replacement battery (A4235) provided on August 5, 2019 to October 24, 2019.You asked the Plan to pay for the blood glucose test or reagent strips, lancets, calibrator solution / chips, and lithium replacement 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 blood glucose test or reagent strips for home blood glucose monitor (A4253), lancets (A4259), calibrator solution / chips (A4256), and lithium replacement battery (A4235) provided on August 5, 2019 to October 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lidocaine (J2001), IV tubing extension set (S1015) and infection control supplies (S8301) used during anesthesia services provided on October 10, 2018.You asked the Plan to pay forthe lidocaine, IV tubing, and infection control supplies. You say that you wish for the codes J2001, S1015, S8301, and E1399 to be reprocessed for payment based on the records submitted.The Plan denied your request. The Plan says there is no documentation of lidocaine for IV injection. In addition, the S-codes are not valid for Medicare payment 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.In this case, the CPT Code Manual definition of code J2001 is Injection, lidocaine hcl for intravenous infusion, 10 mg.We find that CPT code J2001 is not supported in the medical record. Specifically, there is no evidence that lidocaine was used as an intravenous injection. In addition, codes S1015 and S8301 have a status indicator of "I" in the Physician Fee Schedule. This means that they are invalid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the lidocaine, IV tubing, and infection control supplies have not been met.Therefore, we decided that the Plan does not have to pay forthe lidocaine (J2001), IV tubing extension set (S1015) and infection control supplies (S8301) used during anesthesia services provided on October 10, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on May 1, 2019 by an out of network provider, .You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services were rendered by a non-network 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 incases 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 forthe medical services provided on May 1, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copaymentsforthe nasal endoscopiesprovided on June 17, 2019 and July 8, 2019.You asked the Plan to waive the copayments forthe nasal endoscopies. You say that these are follow up visits for sinus surgery. You say that you are only charged $45 for office visits.The Plan denied your request. The Plan says the copayments applied correctly.The rules say a plan must disclose to its enrollees in clear, accurateterms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $295 copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges.You have been asked to pay $168.17, which is less than the standard $295 copayment for each nasal endoscopy. The total amount you owe is $336.34 ($168.17/endoscopy x 2 endoscopies = $336.34). The nasal endoscopies fall within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. Nasal endoscopies are considered a surgical procedure. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayments forthe nasal endoscopies provided on June 17, 2019 and July 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 26, 2019 by 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-network 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 July 26, 2019 by out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on May 23, 2019 by 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-network 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 referring provider 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 May 23, 2019 by out of network provider, Up Services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe fluoroscopic guidance for needle placement provided on July 3, 2019 billed with CPT code 77003.You asked the Plan to pay forthe billed needle guidance. You say that this was billed correctly and should be paid.The Plan denied your request. The Plan says this add-on code was not billed with an appropriate primary procedure meaning it is not payable.The Plan must follow Medicare rules. Medicare rules say that Type I add-on codes have a limited set of primary codes with which they can be reported. CPT code 77003 is a Type I add-on code. The possible primary codes with which it can be reported are 61050, 61055, 62267, 62270, 62272, 62273, 62280, 62281, 62282, 62284, 64510, 64517, 64520, and 64610. In this case, it was reported with 38222.Therefore, we decided that the Plan does not have to pay forthe fluoroscopic guidance for needle placement provided on July 3, 2019 billed with CPT code 77003
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fordiagnostic services provided to the enrollee on May 20, 2019and billed under codes 95955 and 95941.You asked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says Medicare guidance says procedure codes with a status code of "I"are not payable for Medicare services. 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 claim cannot be fully paid due to issues with the status code indicator. Medicare rules for coverage of this service have not been met.Therefore, we decided that the Plan does not have to pay fordiagnostic services provided to the enrollee on May 20, 2019and billed under codes 95955 and 95941.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse the enrollee forhearing aids providedon April 16, 2019.You asked the Plan to reimburse forthe hearing aids. You say that there was a geographic limitation with hi HealthInnovations? and the enrollee's ear canals are oddly shaped and very small and required special fitting for the hearing aids to stay in place and work properly.The Plan denied your request. The Plan says hearing aids must be ordered directly from hi HealthInnovations?.Hearing aids are mailed to you. hiHealthInnovations? hearing aids do not require fitting by an audiologist.Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when ordered directly from hi HealthInnovations?.The benefit is combined in and out-of-network.We looked at the file and the Plan's rules. The requested provider in this case is not a participating hearing services provider with the Plan. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met.Therefore, we decided that the Plan does not have to reimburse forthe hearing aids provided on April 16, 2019.