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

We decided that the Plan does not have to adjust the payment and waive the coinsurance for the power operated vehicle purchased.
You asked the Plan to adjust the payment and waive the coinsurance for the power operated vehicle. You say that you need the scooter but you cannot afford it. The Plan denied your request. The Plan says you have been charged the coinsurance correctly and you upgraded the scooter that was originally approved.
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% coinsurance for Durable Medical Equipment. You have been asked to pay 50% coinsurance for the power operated vehicle. The power operated vehicle falls 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. You upgraded the scooter after approval. Therefore, we decided that the Plan does not have to adjust the payment and waive the coinsurance for the power operated vehicle purchased.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the urgent care services rendered by on August 1, 2019.You asked the Plan to pay for these services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code S9083 is 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. The provider submitted a claim for procedure code S9083 (global fee urgent care centers). This code has a status indicator of I and is not valid for Medicare purposes.Therefore, we decided that the Plan does not have to pay for the urgent care services rendered on August 1, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an x-ray provided by the physician. on June 25, 2019.
You asked the Plan to waive the copayment for an x-ray. You say that you would like this copayment removed. The Plan denied your request. The Plan says the correct copayment has been applied to the service in question.
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 outpatient diagnostic tests/in-networks/x-ray. You have been asked to pay a $35 copayment for an x-ray. Since an x-ray was provided, the correct copayment has been applied. An x-ray falls within the outpatient diagnostic tests/in-networks/x-ray benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an x-ray provided by the physician. on June 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (T1015) you received on June 24, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered service.The Plan must follow Medicare rules. Medicare rules say that a status indicator of "I" under the Physician Fee Schedule indicates that the code in question is not valid for Medicare purposes. We looked at the file and Medicare rules. Code T1015 is assigned a status indicator of "I" under the Physician Fee Schedule, which means that this code is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, these services. 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 (T1015) you received on June 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital discharge day management services provided to the enrollee on September 19, 2018.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 Current Procedural Terminology (CPT) code 99239 (1 Unit) remains not supported.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 99239is "Hospital discharge day management; more than 30 minutes."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 services at issue in this case were not coded correctly. Our coding reviewer found CPT code 99239 is not supported. The record does not contain evidence that more than 30 minutes was spent performing discharge day services. The progress note for this date of service does not contain the amount of time spent performing discharge day management.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 hospital discharge day management services provided to the enrollee on September 19, 2018
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided to the enrollee from August 28, 2019 to August 29, 2019.
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 services should be billed to Original Medicare.
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. The enroll ended Medicare Hospice benefits on August 18, 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 subsequent nursing facility care provided to the enrollee from August 28, 2019 to August 29, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the services (J2778) provided on May 7, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says that documentation of the dosage administered is required.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 J2778 is "Injection, ranibizumab, 0.1 mg".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 code J2778 is supported by the records provided. Our coding reviewer found that the medical documentation provided by the provider states in the procedural note on May 7, 2019, "A single use vial of intravitreal Lucentis 0.5 mg in 0.05 ml was used", which corroborates the dosage at 5 units of ranibizumab billed by the provider.We looked at this coder'sreview, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have been met.Therefore, we decided that the Plan has to pay for the services (J2778) provided on May 7, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0648) provided to the enrollee on
March 8, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your
request. The Plan says the documentation does not indicate services are necessary for treatment of the
enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services,
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for
telehealth services only if they are presented from an authorized originating site located in either a county
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located
in a rural census tract.
A review of the file does not show that the telehealth service was provided in an authorized originating site.
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are
likewise noncovered. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis
(L0648) provided to the enrollee on March 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services (CPT 49999) provided on April 3, 2019.You asked the Plan to pay forthe 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 49999 is "Unlisted procedure, abdomen, peritoneum and omentum".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 49999 is not supported by the records provided. Our coding reviewer found that the record does not contain evidence of the nature, extent, time, and effort, of a procedure that is not included in the description of an existing CPT code.We looked at this coder'sreview, 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 forthe services (CPT 49999) provided on April 3, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to you by an out-of-network provider on January 21, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the services were provided by an out-of-network provider.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay forthe medical services provided to you by an out-of-network provider on January 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on to "the beneficiary" by an out-of-network provider on May 8, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says there is no network deficiency for 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 requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay forthe medical services provided on to"the beneficiary" by an out-of-network provider on May 8, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered from May 8, 2019 to May 31, 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 the claims were not billed correctly.The Plan must follow Medicare rules. The rules say that a treatment authorization code is required for home health claims.We looked at the file and Medicare rules. The file shows that the claims were not billed with the required treatment authorization code. 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 home health services rendered from May 8, 2019 to May 31, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for test strips, lancets, control solution, and batteries provided by HNC Medical Supplies from July 22, 2019 to October 10, 2019.You asked the Plan to pay for test strips (A4253), lancets (A4259), control solution (A4256), and batteries (A4235). You say that the Plan should pay this claim.The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include 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 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. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered.Therefore, we decided that the Plan does not have to pay for test strips, lancets, control solution, and batteries provided from July 22, 2019 to October 10, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered to the enrollee by the Provider on May 22, 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 the enrollee was on hospice.
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. The enrollee ended Medicare Hospice benefits on May 22, 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 the services rendered to to the enrollee by the Provider on May 22, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the knee scooter purchased on June 13, 2019.You asked the Plan to reimburse you for the knee scooter. You say that you had a doctor's prescription for the knee scooter.The Plan denied your request. The Plan says knee scooters are not covered by Medicare or the Plan.The Plan must follow Medicare rules. Medicare rules say that knee scooters are statutorily non-covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the knee scooter have not been met.Therefore, we decided that the Plan does not have to reimburse you for the knee scooter purchased on June 13, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing, presumptive, and definitive provided on August 14, 2019 by the out of network provider.You asked the Plan to pay for the laboratory testing. You say that your types of testing are infinitely more reliable that the more common point of care treatment drug testing. You say that you trust the physician's professional opinion of what is medically necessary for the enrollee and test the submitted specimens according to their orders.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's primary care physician did not refer them for the services. 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 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 drug testing, presumptive, and definitive provided on August 14, 2019 by the out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for hearing aids provided on July 23, 2019.You asked the Plan to reimburse you for the hearing aids. You say that the audiologist's fee for the hearing test was covered and it did not make sense to you to take the results of the hearing exam to another provider to purchase the hearing aids. You say that it was a matter of convenience and the comfort of having the same doctor that did the exam to provide you with hearing aids that the doctorthought wasthe best for you.The Plan denied your request. The Plan says you must see a TruHearing provider to receive the routine hearing aid benefit.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 provided by a TruHearing provider.We looked at the file and the Plan's rules. The requested provider in this case is not a network hearing aid provider. 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 you for hearing aidsprovidedon July 23, 2019
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from July 24, 2019 through July 26, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The Plan denied your request. The Plan says that the stay is 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 supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (ED) and/or observation care) would span two midnights. 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 been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from July 24, 2019 through July 26, 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0673). You asked the Plan to pay for a pneumatic compression device. You say that the device is necessary to prevent deep vein thrombosis.The Plan denied your request. The Plan says the pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery.The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0673) is a preventive service.We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage.Therefore, we decided that the Plan does not have to pay fora pneumatic compression device (E0673).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forhyperthermia treatment (77605 and 77280) provided on October 29, 2018.You asked the Plan to pay forhyperthermia treatment. You say that these services should be considered authorized because of the letter you received from the enrollee's PCP.The Plan denied your request. The Plan says there was no valid referral or authorization for 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 payfor 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. The letter you received about medical clearance does not constitute a valid referral.Therefore, we decided that the Plan does not have to pay forhyperthermia treatment (77605 and 77280) provided on October 29, 2018.