Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services rendered on July 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 97112 is not supported and code 97014 is not covered.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 97112 is therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities.We find that CPT code 97112 is not supported in the medical record. Specifically, there is no documentation of at least eight minutes of therapy spent on the enrollee, the minimum requirement to bill therapy services. Based on this information, we decided that Medicare rules for coverage of these services have not been met. The rules say that a status indicator of I represents a code that is not valid for Medicare purposes.
The provider also submitted a claim for procedure code 97014 (electrical stimulation therapy). 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 physical therapy services rendered on July 1, 2019
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy rendered from August 29, 2019 to September 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 the services are not covered.The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies.We looked at the file and Medicare and the Plan's rules. Based on this information, we decided that Medicare and the Plan's rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay for the home infusion therapy rendered from August 29, 2019 to September 5, 2019.Benefits for these services 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered from July 4, 2019 to July 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. Medicare rules say that home health claims must be billed with a Q code and treatment authorization code.We looked at the file and Medicare rules. The file shows that the claims for these services were not billed with the required Q code and 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 July 4, 2019 to July 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for home health care services provided on November 13, 2018.You asked the Plan to pay for home health services. You say that you are appealing based on medical necessity.The Plan denied your request. The Plan says the denial of payment for these services is correct, because no medical records were furnished to the Plan to support coverage of service.The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the Plan sufficient information to determine whether payment is due for a claim. We looked at the file and Medicare rules. You have not submitted medical records to the Plan to support coverage of the billed service. The Plan made multiple attempts to obtain medical records but none were provided. Without this information, you have not furnished to the Plan sufficient information to justify payment of this claim as billed. Based on this information, we decided that Medicare rules for coverage of home health services have not been met.Therefore, we decided that the Plan does not have to pay for home health care services provided on November 13, 2018.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay fo rthe critical care services rendered on May 17, 2019 to May 21, 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 99291 is 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 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, there is no documentation of 30-74 minutes of critical care services spent on the enrollee. 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 forthe critical care services rendered on May 17, 2019 to May 21, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the ankle/foot orthosis (L1971x2) provided on May 7, 2019.You asked the Plan to pay for the orthoses. You say that the records provided will support the medical necessity of the item L1971.The Plan denied your request. The Plan says the records provided do not support the service billed.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 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 orthoses. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation in the submitted medical records of weakness or deformity of the foot and ankle. There is no specific indication provided to support the medical necessity of this request for foot and ankle stability for functional benefit. Therefore, this request for ankle/foot orthotic x 2 (L1971) is not medically reasonable and necessary.
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 orthoses have not been met.Therefore, we decided that the Plan does not have to pay for the ankle/foot orthosis (L1971x2) provided on May 7, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an ankle-foot orthosis (L1971) 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 non-covered visit are likewise non-covered.Therefore, we decided that the Plan does not have to pay for an ankle-foot orthosis (L1971) provided to the enrollee on March 8, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient services provided to the enrollee by an out-of-network provider from November 1, 2018 to April 12, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services were available 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 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 for the inpatient services provided to the enrollee by an out-of-network provider from November 1, 2018 to April 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to an out-of-network provider on February 14, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the enrollee does not have out-of-network benefits.
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 for the medical services provided to an out-of-network provider on February 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the acupuncture services you received from July 24, 2018, to July 18, 2019.
You asked the Plan to pay for the acupuncture services. You say that you were referred for these services. The Plan denied your request. The Plan says acupuncture is not covered.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. The services at issue in this appeal are acupuncture services. Therefore, we decided that the Plan does not have to pay for the acupuncture services you received from July 24, 2018, to July 18, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for on February 22, 2019 through February 23, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient admission was medically necessary. The Plan denied your request. The Plan says the member's condition could have been handled at a lower level of care.
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 based on the medical records provided the records do not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights. Admission to observation status appears to have been appropriate based on review of the records. 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 on February 22, 2019 through February 23, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.You asked the Plan to pay for the ambulance services. You say that you did not call for the EMT and therefore you should not be held accountable for it.The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on August 8, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on April 19, 2019 by out of network provider.You asked the Plan to pay for physician visit. You say that you were not aware of the enrollee's insurance when you provided service.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 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 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 April 19, 2019 by out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forphysician services provided to the enrollee on August 14, 2019 by"the doctor" .You asked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says the rendering provideris a non-participating providerwith the Plan. The Plan states it did not authorize any services for "the provider" or the ordering physician. The services are not considered urgent/emergent in nature.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-networkproviders 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 forphysician services provided to the enrollee on August 14, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 CFR ?422.101.
The rules say that Medicare will not pay for dental services. Dental services are items and services involving the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this rule in the SSA, Section 1862(a)(12) and Medicare Benefit Policy Manual, Chapter 15, Section 150.
If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. To be covered in-network, you need to use a provider that is contracted with our dental vendor to provide supplemental dental services. Care rendered by a provider that is not part of our supplemental dental network is not covered. You can find this information on page 54 of the Plan's 2019 Evidence of Coverage.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does nothave to pay for post stabilization care.You asked the Plan to pay for the post stabilization care. You say that the post stabilization care was medically necessary. The Plan denied your request. The Plan says the post stabilization care was unauthorizedpost-stabilization care and correctly denied.The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. 
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 post stabilization care. Our reviewer says thatas of 10 am on 12/13/18 the enrollee was hemodynamically stable and appropriate for ambulance transport with monitoring to a Plan facility for continued inpatient level of care services. By this time, all evaluations related to the accident had been completed and the anticipated care plan was to continue supportive treatment involving pain control, non-surgical management of her right foot fracture, and ambulation with PT/OT. Our physician reviewer found post-stabilization care services after 10am on 12/13/2018 were not medically necessary and reasonable.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 post stabilization care have not been met. Therefore, we decided that the Plan does not have to pay for post stabilization care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for non-emergent ambulance services provided from July 1, 2019 through July 30, 2019.
You asked the Plan to waive the copayment for non-emergent ambulance services. You say that you are
appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says the claims
were 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).
Your Evidence of Coverage (EOC) page 60 states that in-network non-emergent ambulance services have a copayment of $265.00. The claims received were less than the copayment, this becomes the member responsibility. 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
non-emergent ambulance services provided from July 1, 2019 through July 30, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for a reimbursement for physical therapy services rendered on April 30, 2019 by the provider.
You asked the Plan to pay for a reimbursement for physical therapy services. You say that you don't understand this denial. The Plan denied your request. The Plan says physical therapy is not covered under your wellness allowance.
The Plan must follow Medicare rules. Medicare rules say that supplemental benefits are benefits not covered under Part A, Part B, or Part D. For that reason, the Plan's rules apply in this case. The Plan rules states that the Wellness allowance only covers the items and services listed above. We looked at the file and Medicare rules. Physical therapy is not covered under the Wellness Allowance benefit. Based on this information, we decided that Medicare rules for coverage of a reimbursement for physical therapy services have not been met. Therefore, we decided that the Plan does not have to pay for a reimbursement for physical therapy services rendered on April 30, 2019 by the provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyeglasses purchased on July 1, 2019.
You asked the Plan to pay for the eyeglasses. You say that you have numerous times over the years and was never notified that you could no longer use them. You feel you should have been made aware of this change. The Plan denied your request. The Plan says enrollee's must receive covered vision care services from an in-network provider. Services received from an out-of-network provider is not covered.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when The plan will provide a $150 allowance towards the purchase price of eyewear from a plan optical facility. We looked at the file and the Plan's rules. For covered vision care services and eyewear, you must go to an in-network, plan optical facility. is not an in-network, plan optical facility. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for the eyeglasses purchased on July 1, 2019.