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

We decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650) provided to the enrollee on March 14, 2019.Youasked the Plan to pay forthe 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 fora lumbar-sacral orthosis (L0650) provided to the enrollee on March 14, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe CPAP supplies provided on July 5, 2019.You asked the Plan to waive the coinsurance forthe CPAP supplies. You say that you cannot afford to pay the coinsurance.The Plan denied your request. The Plan says you were charged the coinsurance 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 20% coinsurance for Durable Medical Equipment and Related Supplies. You have been asked to pay 20% coinsurance for the CPAP supplies. the CPAP supplies falls within the Durable Medical Equipment and Related Supplies 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 CPAP supplies provided on July 5, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that you are unable to get up and down with crutches.
The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
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 pre-approve IRF care. Our reviewer says that the
services are not medically necessary. Our physician reviewer found the records show that you were admitted to
the hospital with right foot pain after a fall with a resulting fracture. You are walking with crutches and need
assistance with transfers. You are medically stable with no complex issues that require an acute hospital
inpatient stay with an interdisciplinary approach to rehabilitation care. You may benefit from further therapy
but do not require an intensive therapy program in an IRF.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF).You asked the Plan to pre-approveadmission to a skilled nursing facility (SNF). You say that the requested admission to a SNF is medically necessary.The Plan denied your request. The Plan says the requested admission to a SNF does not meet criteria.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 pre-approve admission to a skilled nursing facility (SNF). Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee admitted to acute care on 12/20/19 due to a supra-therapeutic INR secondary to inappropriate warfarin usage. From a nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs. His medications included warfarin which was dose adjusted based upon his PT/INR. Regarding rehabilitation services, the enrollee received physical therapy and speech therapy in the acute hospital. The enrollee was independent with functional mobility including gait to 250 feet. He could negotiate 6 stairs with supervision/stand by assist. He had ongoing expressive aphasia. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does not meet 
severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of admission to a skilled nursing facility (SNF) have not been met.Therefore, we decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit (99214) and ophthalmic diagnostic imaging (92133) provided on August 2, 2019.
You asked the Plan to waive the copayment for the specialist visit and diagnostic imaging. You say that you were not aware that there would be an additional charge beyond the $40 copayment for the visit. The Plan denied your request. The Plan says these codes were billed correctly in accordance with your 2019 Evidence of Coverage.
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 $40 copayment for specialist office visit. The Plan also clearly says that you must pay a $65 copayment for outpatient diagnostic procedures. You have been asked to pay a $40 copayment for the specialist visit and a $40.96 copayment for diagnostic imaging. This is less than the contracted amount as stated in your Evidence of Coverage.
The specialist visit falls within the physician services benefit category and the diagnostic imaging falls within the outpatient diagnostic tests 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 a specialist visit (99214) and ophthalmic diagnostic imaging (92133) provided on August 2, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a wrist-hand orthosis (L3916) provided to the enrollee on March 26, 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 wrist-hand orthosis (L3916) provided to the enrollee on March 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan has to pay for the revision arthroplasty of the left ankle provided on July 5, 2019 by the out of network provider.
You asked the Plan to pay for the surgical services. You say that your Medicare A and B plans were reversed without your knowledge. You also say that you were under the impression that SCAN was secondary to Medicare. The Plan denied your request. The Plan says that the services you received were not emergent or urgent. The Plan also says the services you received were not authorized.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. the Plan did not provide a copy of the applicable Evidence of Coverage for this case. We asked for this document but it was not provided to us. Without this information we cannot determine that the Plan's coverage rules support the denial of payment in this case, or that the enrollee has been adequately notified of the Plan's coverage rules and benefits. Therefore the Plan has not substantiated their denial of payment in this case. Therefore, we decided that the Plan has to pay for the revision arthroplasty of the left ankle provided on July 5, 2019 by the out of network provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ambulance trip provided on August 25, 2019.
You asked the Plan to waive the copayment for an ambulance trip. You say that this copayment is excessive. The Plan denied your request. The Plan says the correct copayment has 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 $175 copayment for ambulance services/ambulance transport. The enrollee has been asked to pay a $175 copayment for an ambulance trip. Since an ambulance trip was provided, the correct copayment has been applied. An ambulance trip falls within the ambulance services/ambulance transport 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 an ambulance trip provided on August 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe assembly and operation of pump with oxygenator or heat exchanger coded 99190 provided on August 2, 2019.You asked the Plan to pay forthe assembly and operation of pump with oxygenator or heat exchanger. 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 separately payable.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 99190 is Assembly and operation of pump with oxygenator or heat exchanger (with or without ECG and/or pressure monitoring); each hour.We find that CPT code 99190 is not supported in the medical record. Specifically, the enrollee was inpatient for these services. Therefore, the payment for these services is the responsibility of the facility to any vendor. Based on this information, we decided that Medicare rules for coverage of the assembly and operation of pump with oxygenator or heat exchanger have not been met.Therefore, we decided that the Plan does not have to pay forthe assembly and operation of pump with oxygenator or heat exchanger coded 99190 provided on August 2, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical evaluation treatment package with procedure code S9986 provided on August 1, 2019.
You asked the Plan to pay for evaluation service. You say that you are requesting reimbursement for this service. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this service is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that procedure code S9986 is not valid for Medicare purposes and is not payable. We looked at the file and Medicare rules. This service is not payable by Medicare as it has been billed by the provider. Based on this information, we decided that Medicare rules for coverage of evaluation service have not been met. Therefore, we decided that the Plan does not have to pay for surgical evaluation treatment package with procedure code S9986 provided on August 1, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tadalafil for "the beneficiary".You asked the Plan to pre-approveTadalafil. You say that the enrollee tried Tadalafil, and had significant improvement with his symptoms.The Plan denied your request. The Plan says drug coverage is limited to Part B covered drugs.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. 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 pre-approve Tadalafil for "the beneficiary". Benefits for Tadalafilmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea home ventilator (E0466).You asked the Plan to pre-approvea home ventilator (E0466). You say that the requested home ventilator is medically necessary.The Plan denied your request. The Plan says the requested home ventilator does not meet criteria.The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD.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 pre-approve a home ventilator (E0466). Our reviewer says that the requested home ventilator does not meet criteria. Our physician reviewer found this enrollee was started on a home ventilator in December, 2016, after a hospitalization for chronic obstructive pulmonarydisease (COPD) exacerbation. She has chronic hypercarbic and hypoxic respiratory failure due to COPD. She is a good candidate for nocturnal respiratory support, and she is benefiting from it, but it appears that BiPAP will meet her needs. She has not beentried on BiPAP in the home setting when medically stable, so there is no documentation of BiPAP failure. She improved while on BiPAP in the hospital. The ventilator is using the AVAPS-AE mode of ventilation, which can be provided by specific BiPAP devices. Medicare does not cover home ventilators when used as BiPAP. A home ventilator is not medically necessary in this case. The enrollee would be expected to qualify for BiPAP coverage.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a home ventilator (E0466) have not been met.Therefore, we decided that the Plan does not have to pre-approvea home ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe glucose monitor, test strips, lancets, control solution, and lancet device provided from May 31, 2019 to August 19, 2019.
You asked the Plan to pay forthe glucose monitor(E2100), test strips (A4253), lancets (A4259), control solution (A4256), and lancet device (A4258). 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 forthe glucose monitor, test strips, lancets, control solution, and lancet device provided from May 31, 2019 to August 19, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the colonoscopy provided on July 30, 2019.
You asked the Plan to waive the cost share for the colonoscopy. You say that you were informed this would be covered since it is a screening. You say that you feel you don't owe this amount. The Plan denied your request. The Plan says the cost share 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). The enrollee's contract with the Plan clearly says that your deductible is $750. This is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. The enrollee's contract with the Plan clearly says that enrollees must pay a $125 copayment after the deductible is met for each outpatient surgery and/or services at an ambulatory surgical center or outpatient hospital facility. The colonoscopy you asked the Plan to waive the cost share for falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $750 deductible applies to outpatient surgery. This cost sharing is a contractual obligation that had not been met at the time the colonoscopy was received on July 30, 2019.
Since your $750 deductible was met, you have also been asked to pay the $125 copayment. The records show that three polyps were removed, which makes this a surgical procedure. 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 cost share for the colonoscopy provided on July 30, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic mammogram provided on August 6, 2019.
You asked the Plan to waive the copayment for a diagnostic mammogram. You say that you paid for your first mammogram. You say that you do not feel like you should be charged an additional copayment. The Plan denied your request. The Plan says the correct copayment has 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). Your contract with the Plan clearly says that you must pay a $40 copayment for outpatient diagnostic tests/basic imaging service. You have been asked to pay a $40 copayment for a diagnostic mammogram. Since the mammogram that was provided was diagnostic in nature, the correct copayment has been applied. A diagnostic mammogram falls within the outpatient diagnostic tests/basic imaging service 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 a diagnostic mammogram provided on August 6, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0483 provided on May 8, 2019.
You asked the Plan to pay for the drug testing. 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 G0483 is Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed. We find that CPT code G0483 is not supported in the medical record. Specifically, the documentation submitted did not include a valid physician order/lab requisition or medical records (signed by the ordering physician); therefore, the billed code cannot be verified. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded G0483 provided on May 8, 2019.