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

We decided that the Plan does not have to pay for the services provided to the enrollee on February 21, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says the enrollee was enrollee in a hospice program.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay forthe services provided to the enrollee on February 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical nutrition therapy services provided to the enrollee on August 16, 2019.You asked the Plan to pay for medical nutrition therapy services. You say that the services were medically necessary.The Plan denied your request. The Plan says this is a non-covered service.The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services only for enrollees with renal disease or diabetes. The records do not show that the enrollee suffers from renal disease or diabetes.Therefore, we decided that the Plan does not have to pay for the medical nutrition therapy services provided to the enrollee on August 16, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aid services provided to the enrollee on April 17, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were provided by a provider who is outside of the vendor network.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 they are ordered through the provider. We looked at the file and the Plan's rules.The records show that the hearing aid services were provided by a provider who is outside of the plan's vendor network. Based on this information, we decided that the Plan's rules for coverage of the services have not been met.Therefore, we decided that the Plan does not have to pay for the hearing aid services provided to the enrollee on April 17, 2019
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the first 30-74 minutes of critical care (99291 x 2) provided on January 26, 2019 through January 27, 2019.You asked the Plan to pay for the critical care services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted did not support a critical care visit of 30-74 minutes was performed on the billed dates of service.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 99291is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes.We find that CPT code 99291 is not supported in the record. Specifically, the record does not indicate that 30-74 minutes of critical care services were rendered. Based on this information, we decided that Medicare rules for coverage of the critical care services have not been met. Therefore, we decided that the Plan does not have to pay for the first 30-74 minutes of critical care (99291 x 2) provided on January 26, 2019 through January 27, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 15734-LT, CPT 15734-RT) provided to the enrollee on March 7, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this code cannot be verified.
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 15734 is "Muscle, myocutaneous, or fasciocutaneous flap; trunk". We asked our coding 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 services. Our reviewer says that the use of CPT code 15734 is not supported by the records provided. Our coding reviewer found that the record does not contain evidence that a muscle flap or graft was created to transfer muscle to close a defect. We looked at this coder's review, the file, and Medicare rules. 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 the services (CPT 15734-LT, CPT 15734-RT) provided to the enrollee on March 7, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered to the enrollee by the practice on June 5, 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 physician order.The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided tha tthe Plan does not have to pay for the drug testing rendered to the enrollee by the practice on June 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on June 19, 2019 by out of network provider.
You asked the Plan to pay for physician services. You say that you were unaware that prior authorization was required. 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 the medical services provided on June 19, 2019 by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 99239) provided to the enrollee on June 3, 2019.You asked the Plan to pay for the services. You say that the enrollee was not in hospice.The Plan denied your request. The Plan says the enrollee was enrolled in hospice.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. the enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay for the services (CPT 99239) provided to the enrollee on June 3, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services provided on June 7, 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-participating 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 forthe laboratory services provided on June 7, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge day management (99239) provided on September 26, 2018.
You asked the Plan to pay for the hospital discharge day management. You say that please review the radiology reports and process the claim for payment. The Plan denied your request. The Plan says there is insufficient documentation to corroborate the services and confirm Medicare coverage has been met.
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 99239 is the hospital discharge day management, with a duration time of 31 minutes or more. We find that CPT code 99239 is not supported in the medical record. Specifically, the documentation submitted does not include a hospital discharge day management note with a recorded duration of time of 31 minutes or more. Based on this information, we decided that Medicare rules for coverage of the hospital discharge day management have not been met. Therefore, we decided that the Plan does not have to pay for the hospital discharge day management (99239) provided on September 26, 2018.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from May 8, 2019 to May 10, 2019.You asked the Plan to pay for acute inpatient hospital care. You say that the acute inpatient hospital care provided from May 8, 2019 to May 10, 2019 was medically necessary.The Plan denied your request. The Plan says the acute inpatient hospital care provided from May 8, 2019 to May 10, 2019 was not medically necessary.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee was evaluated in the emergency department for chest pain. Ongoing care was ordered which included serial cardiac enzymes, telemetry monitoring, and cardiology consultation. The enrollee was kept for a second night for a scheduled cardiac stress test which was cancelled as an outpatient stress was also scheduled. Care provided to the enrollee was observation level. There were no advance interventions or complex medical conditions. She had stable vital signs and no complaints at the time of admission. During the hospital courses, pain was noted to be reproducible. Inpatient care services were not supported by the documentation.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met.Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from May 8, 2019 to May 10, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe emergency room services provided on July 13, 2019.You asked the Plan to waive the coinsurance forthe emergency room services. You say that you feel you should not be responsible for this cost share amount and you would like the plan to reconsider your request.The Plan denied your request. The Plan says you received emergency care services on the date of service at issue in this appeal. The plan states the correct coinsurance has applied per your contract with the plan.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 up to $80 max copay for Medicare-covered emergency room visits. We looked at the file, the Plan's contract and Medicare rules. The file shows that you were examined by a physician in the emergency department prior to being released against medical advice on July 13, 2019. You have been asked to paya 20% coinsurance for the emergency room services, totaling $57.82. The emergency room services fall within the Emergency 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 coinsurance forthe emergency room services provided on July 13, 2019.Your complaint about not being treated by this provider 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: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on October 4, 2018.
You asked the Plan to waive the copayment for the ambulance transport. You say that you were not given a choice for the type of transportation. You say that you should have been given a wheelchair and a normal transport. 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 $200 copayment for each one-way trip. You have been asked to pay a $200 copayment for the ambulance transport. The ambulance transport falls within the "Ambulance services" benefit category. The records show that you were transported by ambulance to the cardiologist's office. 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 ambulance transport provided on October 4, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe outpatient hypertheramia treatments provided on October 9, 2018 by an out of network provider.You asked the Plan to pay forthe outpatient hypertheramia treatments. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services rendered 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 forthe outpatient hypertheramia treatments provided on October 9, 2018.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe SNF stay provided by from January 9, 2019 to February 11, 2019.You asked the Plan to waive the copayment forthe SNF stay. You say that you were not told by the facility that you were nolong going to be covered by the insurance. 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 for days 1-20 for Medicare-covered stays a SNF. You pay a $25 copayment per day for days 21-100 for Medicare-covered stays at a SNF. You have been asked to pay a $250 copayment for each day, days 23-33 the SNF stay. ($25 x 10 days = $250). The SNF stay falls within the "Skilled nursing facility (SNF) care" benefit category. The record shows you were billed $250 from February 1, 2019 to February 11, 2019. 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 doesnot have to waive the copayment forthe SNF stay provided from January 9, 2019 to February 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe chiropractic services (CPT 97112, CPT 97032, CPT 99214) provided from May 1, 2019, to May 15, 2019.You asked the Plan to pay forthe chiropractic services. You say that the services were medically necessary.The Plandenied your request. The Plan says the requested services are a non-covered benefit.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 services at issue are not manual manipulation of the spine.Therefore, we decided that the Plan does not have to pay forthe chiropractic services (CPT 97112, CPT 97032, CPT 99214) provided from May 1, 2019, to May 15, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a vision supply, accessory and/or service component of another vision code provided.
You asked the Plan to pay for the vision supply, accessory and/or service component of another vision code. The Plan denied your request. The Plan says they pay for eyeglasses (lenses and frames) and contact lenses and the enrollee is responsible for any remaining costs.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file and the Plan's rules. The Plan pays for eyeglasses (lenses and frames) and contact lenses and the enrollee is responsible for any remaining costs. Therefore, we decided that the Plan does not have to pay for a vision supply, accessory and/or service component of another vision code provided.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for diabetic supplies provided by the Provider from August 13, 2019 to November 1, 2019.
You asked the Plan to pay for diabetic supplies. You say that you are appealing with records. The Plan denied your request. The Plan says the denial of payment for these items is correct, because the delivery ticket submitted did not include the carrier's tracking number and the proof of delivery did not include an order number to corroborate the delivery ticket.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for diabetic supplies provided by the Provider from August 13, 2019 to November 1, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for services provided by the Provider on September 6, 2019.
You asked the Plan to pay for the ambulance services. You say that the enrollee revoked hospice before the transport. The Plan denied your request. The Plan says Original Medicare is responsible for this claim.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. Enrollee's ended Medicare Hospice benefits on September 6, 2019. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for services provided by the Provider on September 6, 2019.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for services provided on May 23, 2019.You asked the Plan to pay for the ambulance services. You say that the ambulance services were medically necessary.The Plan denied your request. The Plan says that the enrollee could have been safely transported by another type of vehicle.Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. 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 ambulance services. Our physician reviewer found based on the documentation provided that transportation via ambulance to the Emergency Department was medically necessary and reasonable.  The enrollee did require the expertise of trained personnel or the equipment available only on an ambulance in order to effectuate a safe transport.  Transportation could not have been provided by other means (stretcher van, wheelchair van, private car, taxi) without endangering the enrollee's condition. A prudent layperson would believe that immediate medical attention was required for someone, who was experiencing pain, which may have been related to a recent cardiac procedure.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 ambulance services have been met.Therefore, we decided that the Plan has to pay for services provided by on May 23, 2019.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.