Persius/hicric huggingface dataset:
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 September 23, 2020.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for a shoulder-hand-wrist orthosis (L3960) provided to the enrollee on September 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiac device monitoring services (93293) provided on November 25, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the cardiac device monitoring services (. You say that you know that you are a non-participating provider but the services provided to the enrollee are medically necessary. Please reconsider your claim with the information obtained in this appeal letter. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

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 had network providers available who could have provided 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 cardiac device monitoring services (93293) provided on November 25, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for incontinence supplies.

You asked the Plan to pay for incontinence supplies. You say that the supplies are too expensive; they should be covered by Medicare. The Plan denied your request. The Plan says the incontinence supplies are covered by Medicaid, not Medicare.

The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. 

While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. The plan confirmed that supplies are covered by Medicaid and the provider will bill Medicaid instead. Provider has confirmed that they are billing Medicaid and nothing is from you at this time. Therefore, we decided that the Plan does not have to pay for incontinence supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a provider visit provided on November 10, 2020 by an out of network (OON) provider.

You asked the Plan to pay for provider visit. You say that your provider depends upon the facility staff to verify eligibility and obtain proper authorization. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and authorization was not 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 had network providers available who could have provided 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 provider visit provided on November 10, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound (93306) and an endoscopy (43235) provided from September 23, 2020, to October 13, 2020.

You asked the Plan to waive the copayment for an ultrasound and an endoscopy. You say that you believe you were charged these amounts in error. The Plan denied your request. The Plan says these services processed 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 $160 copayment for each Medicare-covered radiological diagnostic service, including ultrasounds, and a $390 copayment for Medicare-covered surgery services.

You have been asked to pay a $160 copayment for an ultrasound, which is a radiological diagnostic service, and a $390 copayment for an endoscopy, which is a surgery 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 an ultrasound (93306) and an endoscopy (43235) provided from September 23, 2020, to October 13, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health services (90832) provided on August 6, 2020.

You asked the Plan to pay for the outpatient mental health services. You say that the services were medically necessary. The Plan denied your request. The Plan says the out-of-network services were not emergent or pre-authorized.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for outpatient mental health services (90832) provided on August 6, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for surgical services (17311, 13132) provided October 28, 2020.

You asked the Plan to waive the co-payment for the surgical services. You say that the co-payment should be waived. The Plan denied your request. The Plan says the correct co-payment was applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 co-payment for Outpatient Surgery.

You have been asked to pay a $350 co-payment for the surgical services. the surgical services falls within the Outpatient Surgery 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 co-payment for surgical services (17311, 13132) provided October 28, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (CPT 80307 and HCPCS G0481) services provided to the enrollee on August 4, 2020.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained.

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 80307 and HCPCS G0481 are not supported in the medical record. Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's office (POS 11). 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 (CPT 80307 and HCPCS G0481) services provided to the enrollee on August 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the humidifier used with a positive airway pressure device (E0562) and respiratory assist device (E0470) provided July 9, 2020, to November 9, 2020.

You asked the Plan to waive the coinsurance for the humidifier used with a positive airway pressure device and respiratory assist device. You say that you never signed a lease and believed it was a one time purchase. The Plan denied your request. The Plan says the cost share has processed correctly in this case.

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 durable medical equipment.

You have been asked to pay a total cost share of $162.45 for the humidifier used with a positive airway pressure device and respiratory assist device ($812.20 allowed amount x 20% coinsurance). These items fall within the durable medical equipment 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 humidifier used with a positive airway pressure device (E0562) and respiratory assist device (E0470) provided July 9, 2020, to November 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Unna boot strapping services rendered on November 23, 2020.
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 code 29580 is not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. The provider submitted a claim for procedure codes 29580 and 11042. Code 29580 is a column II code with a modifier indicator of 1 when billed with column I code 11042. Code 29580 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the Unna boot strapping services rendered on November 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for an informational/resource book, Keto Diet for Dummies.

You asked the Plan to reimburse you for the informational/resource book, Keto Diet for Dummies. The Plan denied your request. The Plan says nutrition/dietary support program includes general nutrition education through classes and/or individual counseling. For weight management programs it states qualified programs may be offered in person or online (full or partly). The program should provide structured lessons on a weekly basis tailored to your personal goals.

The Plan contract offers a supplemental Wellness Wallet benefit. 

We looked at the file and the Plan's rules. The file shows that the Keto Diet for Dummies book is not a Wellness Wallet benefit under your Plan. Therefore, we decided that the Plan does not have to reimburse you for an informational/resource book, Keto Diet for Dummies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the portable oxygen concentrator purchased June 9, 2020.

You asked the Plan to pay for the portable oxygen concentrator. You say that you would like the Plan to reconsider payment for the services received. The Plan denied your request. The Plan says purchased oxygen is statutorily non-covered.

The Plan must follow Medicare rules. Medicare rules say that oxygen equipment that is purchased not rented is not eligible for payment.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the portable oxygen concentrator have not been met. Therefore, we decided that the Plan does not have to pay for the portable oxygen concentrator purchased June 9, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on June 22, 2020.

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 80157, 80177, 80201, 80162, 80159, and 80173 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.

We find that CPT codes 80157, 80177, 80201, 80162, 80159, and 80173 are not supported in the medical record. Specifically, the records show that the testing was performed on urine specimens and not blood specimens. 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 laboratory services rendered on June 22, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit provided on December 15, 2020 by an OON provider.

You asked the Plan to pay for the home visit. You say that you believe these services should be covered. The Plan denied your request. The Plan says the service was rendered by a non-participating provider. The Plan also says that prior authorization was not 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 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 home visit provided on December 15, 2020 by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on September 21, 2020 by an out of network (OON) provider.

You asked the Plan to pay for these services. You say that your previous naturopath services were covered. The Plan denied your request. The Plan says the services were rendered by an out-of-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 had network providers available who could have provided 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 September 21, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99213) provided on January 28, 2020 by an out of network (OON) provider.

You asked the Plan to pay for an OON office visit. You say that this provider is Medicare-certified. The Plan denied your request. The Plan says this provider is not in-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 had network providers available who could have provided 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 an office visit (99213) provided on January 28, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a consultation (D9310), and intravenous moderate sedation (D9239, D9243 x2) provided on August 19, 2020.

You asked the Plan to pay for a consultation, and intravenous moderate sedation. You say that you would like the Plan to pay for these services. The Plan denied your request. The Plan says these services are not a covered benefit.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a consultation (D9310), and intravenous moderate sedation (D9239, D9243 x2) provided on August 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the preventive medicine counseling, gastric band adjustment, and nutritional counseling rendered on August 20, 2020 to September 21, 2020.

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 are not covered.

The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid for Medicare purposes and a status indicator of N represents non-covered services. 

We looked at the file and Medicare rules. Billed procedure codes S2083 (adjustment of gastric band) and S9470 (nutritional counseling) have a status indicator of I and are not valid for Medicare purposes. Code 99401 (preventive medicine counseling) has a status indicator of N and is non-covered. Therefore, we decided that the Plan does not have to pay for the preventive medicine counseling, gastric band adjustment, and nutritional counseling rendered on August 20, 2020 to September 21, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on December 9, 2020 by an out of network (OON) 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 an out-of-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 had network providers available who could have provided 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 December 9, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on November 25, 2020 by an out of network (OON) 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 an out-of-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 had network providers available who could have provided 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 November 25, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on June 22, 2020.

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 claim was billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code.

We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on June 22, 2020.