Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forinpatient hospital care provided from August 14, 2019 through August 15, 2019.You asked the Plan to waive the copayment forinpatient hospital care. You say that you were unaware there is a $300 deductible for inpatient hospital care.The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received inpatient hospital care from August 14, 2019 through August 15, 2019. Your EOC clearly states, you pay a deductible of $300 per calendar yearfor covered services received in a general acute care hospital. 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 forinpatient hospital care provided from August 14, 2019 through August 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forwound debridement provided from May 3, 2019 through May 24, 2019.You asked the Plan to waive the copayments forwound debridement. You say that you are disputing the cost.The Plan denied your request. The Plan says the copayments applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copaymentfor Medicare-covered surgery or other services at an outpatient hospital or ambulatory surgical center.You have been asked to pay a $250 copayment for each wound debridement visit. The total amount you owe is $1,000 ($250/visit x 4 visits = $1,000). Wound debridement falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. Wound debridement is considered a surgical procedure. This means that you have beenasked 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 forwound debridement provided from May 3, 2019 through May 24, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided to the enrollee on June 20, 2019.
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided to the enrollee on June 20, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe discharge services (CPT 99239) provided on November 28, 2018.You asked the Plan to pay forthe discharge services. The Plan denied your request. The Plan says the billed service 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 99239 is "Hospital discharge day management; more than 30 minutes".We find that CPT code 99239 is not supported in the medical record. Specifically, the records provided do not show that more than 30 minutes of discharge day management services were provided on the date of service in question. Based on this information, we decided that Medicare rules for coverage of the discharge services have not been met.Therefore, we decided that the Plan does not have to pay forthe discharge services (CPT 99239) provided on November 28, 2018.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing services provided to "the beneficiary" on June 5, 2019.You asked the Plan to pay forthe drug testing services. The Plan denied your request. The Plan says the documentation submitted did not include a physician order/lab requisition or medical records stating exactly what tests are to be performed.The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed.We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met.Therefore, we decided that the Plan does not have to pay forthe drug testing services provided to "the beneficiary" on June 5, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy provided from July 28, 2019 to August 4, 2019.You asked the Plan to pay for the therapy. You say that this should be paid for.The Plan denied your request. The Plan says this code is not valid for Medicare purposes.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.We find that HCPCS code S9328 is not supported in the medical record. Specifically, this code has a status indicator of I according to the Medicare Physician's Fee Schedule. This indicates that the code is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the therapy have not been met.Therefore, we decided that the Plan does not have to pay for home infusion therapy provided from July 28, 2019 to August 4, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay forthe closed treatment of patellar fracture services coded 27520 provided on May 16, 2019.You asked the Plan to pay forthe closed treatment of patellar fracture 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 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 27520 is Closed treatment of patellar fracture, without manipulation.We find that CPT code 27520 is not supported in the medical record. Specifically, the documentation submitted did not include documentation of closed treatment of patellar fracture, without manipulation, therefore, the billed service cannot be verified. Based on this information, we decided that Medicare rules for coverage of the closed treatment of patellar fracture services have not been met.Therefore, we decided that the Plan does not have to pay forthe closed treatment of patellar fracture services coded 27520 provided on May 16, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) provided by the doctor on September 25, 2019.
You asked the Plan to pay for the periodic oral evaluation. You say that you went to the dentist to see if a chipped tooth was a hazard to your health. The Plan denied your request. The Plan says your claim was denied as you have exceeded the allowable frequency per calendar year for this 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. We looked at the case file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the periodic oral evaluation have not been met. Specifically, you have exceeded the allowable frequency per calendar year for this benefit as you have received an oral evaluation on March 20, 2019 and September 19, 2019 previously. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120) provided on September 25, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical and occupational therapy provided on June 22, 2019 to June 30, 2019.
You asked the Plan to waive the copayment for physical and occupational therapy. You say that this has been a financial burden for the enrollee. The Plan denied your request. The Plan says the correct copayments have been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $40 copayment for outpatient rehabilitation services. The enrollee has been asked to pay less than a $40 copayment for physical and occupational therapy. The total amount you are being asked to pay is $320 which is less than your copayment amount of $920 ($40 x 23 = $920). Physical and occupational therapy falls within the outpatient rehabilitation services benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for physical and occupational therapy provided on June 22, 2019 to June 30, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic screening testing provided on May 6, 2019.
You asked the Plan to pay for genetic tests. You say that you are appealing with records. The Plan denied your request. The Plan says the denial of payment for these services is correct, because these tests were ordered by telemedicine which is a Medicare prohibited action.
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 genetic screening testing provided on May 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on June 13, 2018.You asked the Plan to pay for the 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 are likewise noncovered.Therefore, we decided that the Plan does not have to pay for knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on June 13, 2018.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing, definitive, and presumptive provided on
August 7, 2019 by the out of network provider.
You asked the Plan to pay for the laboratory testing. You say that you trust the physician's professional opinion
of what is medically necessary for their patient 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 was referred for the services by another non-participating provider. The
Plan also says there is no evidence the services were provided to the enrollee in an emergent situation.
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 physician 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 drug
testing, definitive, and presumptive provided on August 7, 2019 by the out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lab services provided to "the beneficiary" on April 11, 2019.You asked the Plan to pay forthe lab services. The Plan denied your request. The Plan says it cannot be determined how the enrollee came to the servicing provider, or whether the services are medically necessary.The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. We looked at the file and Medicare rules. The documentation provided does not contain medical records from the rendered provider or the ordering provider. Without records, it cannot be determined that Medicare coverage criteria have been met. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met.Therefore, we decided that the Plan does not have to pay forthe lab services provided to "the beneficiary" on April 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the speech generating device provided to the enrollee on July 1, 2019.
You asked the Plan to pay for the speech generating device. You say that The Plan denied your request. The Plan says that the documentation submitted did not include an itemized shipping/billing invoice to indicate the specific supplies, or proof of delivery.
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 proof of delivery submitted does not include the items delivered. Therefore, we decided that the Plan does not have to pay for the speech generating device provided to the enrollee on July 1, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forcritical care services 99291 provided June 3, 2019 to June 6, 2019.You asked the Plan to pay forthe critical care services. You say that the records provided should support the necessity of the services in dispute.The Plandenied your request. The Plan says the records do not support the service billed.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 99291 is 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 medical record. Specifically, the documentation submitted does not include critical care progress notes for the billed dates. Critical care time must be documented. 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 forcritical care services 99291 provided on June 3, 2019 to June 6, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit or pay for the
self-administered drugs provided from October 29, 2018 to November 6, 2018,
You asked the Plan to waive the copayment for the emergency room visit and pay for the self-administered
drugs. You say that you should have been admitted to the hospital and not observation. The Plan denied your
request. The Plan says that you are responsible for the cost-sharing and that self-administered drugs are not
covered.
The rules say that Medicare Part B generally does not pay for self-administered drugs. The rules also 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 $100 copayment for
each emergency room visit.
You have been asked to pay a $100 copayment for the emergency room visit and to pay for the selfadministered
drugs. The emergency room visit falls within the emergency room visit benefit category. This
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. The self-administered
drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided
that the Plan does not have to waive the copayment for the emergency room visit or pay for the selfadministered
drugs provided from October 29, 2018 to November 6, 2018,
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe abdominal ultrasound provided on May 30, 2019 by the out of network provider.You asked the Plan to pay forthe radiology services. You say that the enrollee was inpatient when she received the service. You say that an in network provider was  unavailable.The Plan denied your request. The Plan says authorization was not obtained before the services were provided to the enrollee. The Plan also says the services were not Plan directed.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 forthe abdominal ultrasound provided on May 30, 2019 by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foran office visit (99213), removal of foreign body of foot tissue (28190), and an x-ray of the foot (73620) provided on June 17, 2019 by out of network provider, "the doctor".You asked the Plan to pay foran office visit, removal of foreign body of foot tissue, and an x-ray. You say that the patient has been a long-time patient of "the doctor" for foot care. You say that the patient did not present the staff withher new insurance nor did she present an authorization for services.The Plan denied your request. The Plan says it requires the utilization of in network providers unless the plan pre-approves out of network services in non-emergent situations. The Plan says there is no evidence that the provider contacted the plan to verify insurance, current eligibility, or authorization requirements. The Plan also says the provider failed to request prior authorization before rendering services. There is also no evidence of plan directed care.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 foran office visit (99213), removal of foreign body of foot tissue (28190), and an x-ray of the foot (73620) provided on June 17, 2019 by out of network provider, "the doctor".