Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network provider from May 7, 2019, to June 3, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 you by an out-of-network provider from May 7, 2019, to June 3, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveEszopiclone for the enrollee.You asked the Plan to pre-approveEszopiclone. The Plan denied your request. The Plan says that this is not covered under Part B.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-approveEszopiclone for the enrollee.Benefits for Eszopiclonemay be available under Medicare Part D.Contactthe 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 for the moderate sedation services rendered to the enrollee.
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 payment is included in the facility payment.
The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component (TC) indicator of 3 represents TC only codes. Quantum Radiology submitted a claim for procedure code 99153 with place of service code 22 for outpatient hospital. This code has a PC/TC status indicator of 3 and no separate PC payment. Payment is included in payment to the facility. Therefore, we decided that the Plan does not have to pay for the moderate sedation services rendered to the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment formagnetic resonance imaging (an MRI) (73721) provided by "the provider" on July 1, 2019.You asked the Plan to waive the copayment foran MRI. You say that you were not aware that there would be a charge or copay for the service on your knees. You say that you called "the plan" and "the provider" before the procedure and they both said that it would be covered all by your insurance. Your further state if you knew there would be a partial payment, you wouldn't have had the procedure done.The Plan denied your request. The Plan says outpatient diagnostic tests have a $60 copayment when services are performed by a provider other than your primary care physician.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 $60 copayment for outpatient diagnostic tests. You have been asked to pay a $60 copayment for an MRI. This servicefalls within the outpatient diagnostic tests benefit category. This means that you have been askedto 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 formagnetic resonance imaging (an MRI) (73721) provided by "the provider" on July 1, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for test strips (A4253), lancets (A4259), calibrator solution (A4256), and batteries (A4235) provided on August 13, 2019.
You asked the Plan to pay for test strips, lancets, calibrator solution, and batteries. You say that these items should be covered. The Plan denied your request. The Plan says the delivery ticket submitted did not include the carrier's tracking number, nor did the proof of delivery include an order number or 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 physician order and 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. Specifically, the delivery ticket and the proof of delivery did not corroborate one another in regards to an order number and carrier. Therefore, we decided that the Plan does not have to pay for test strips (A4253), lancets (A4259), calibrator solution (A4256), and batteries (A4235) provided on August 13, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the diabetic supplies rendered to the enrollee by the practice on August 6, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says there is no valid proof of delivery.
The Plan must follow Medicare rules. The rules say that all DMEPOS suppliers are required to maintain proof of delivery. We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. 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 diabetic supplies rendered to the enrollee by the practice on August 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for 30 minutes of advanced care planning provided on May 20, 2019.
You asked the Plan to pay for the advanced care planning. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the submitted documentation does not include the discussion between the provider, along with family members or surrogates regarding the eventual end-of-life decisions and preference.
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 99497 is advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate We find that CPT code 99497 is not supported in the record. Specifically, the record does not indicate that 30 minutes of advanced care planning was performed. Based on this information, we decided that Medicare rules for coverage of the advanced care planning have not been met. Therefore, we decided that the Plan does not have to pay for 30 minutes of advanced care planning provided on May 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services provided to the enrollee on July 9, 2019.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says coverage extends only to treatment by means of manual manipulation of the spine to correct subluxation.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The file shows that the enrollee received mechanical traction therapy, electrical stimulation, and manual therapy techniques. The records show that the services at issue is not manual manipulation of the spine. These services are not covered by Medicare or the enrollee's plan when provided by a chiropractor. Therefore, we decided that the Plan does not have to pay for the chiropractic services provided to the enrollee on July 9, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the diabetic supplies billed for services provided to the enrollee from May 24, 2019 to August 12, 2019.
You asked the Plan to pay for the diabetic supplies. The Plan denied your request. The Plan says the proof of delivery details do not corroborate with 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 a valid proof of delivery documentation for the items at issue in this appeal. The record does not contain valid proof of delivery for the supplies provided in this case. Therefore, we decided that the Plan does not have to pay for the diabetic supplies billed for services provided to the enrollee from May 24, 2019 to August 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for test strips (A4253), lancets (A4259), calibrator solution
(A4256), and batteries (A4235) provided on August 10, 2019 to October 29, 2019.
You asked the Plan to pay for test strips, lancets, calibrator solution, and batteries. You say that these items
should be covered. The Plan denied your request. The Plan says the delivery ticket submitted did not include
the carrier's tracking number, nor did the proof of delivery include an order number or 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 physician order and 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. Specifically, the delivery ticket and the proof of delivery did not corroborate one
another in regards to an order number and carrier. Therefore, we decided that the Plan does not have to pay for
test strips (A4253), lancets (A4259), calibrator solution (A4256), and batteries (A4235) provided on August 10,
2019 to October 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the special pump services rendered to the enrollee by the practice on July 17, 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 separately payable.
The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of X are statutorily excluded. The provider submitted a claim for procedure code 99190 (special pump services). This code has a status indicator of X and no separate Medicare payment. Payment is included in the payment to the facility. Therefore, we decided that the Plan does not have to pay for the special pump services rendered to the enrollee by the practice on July 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the federally-qualified health center (FQHC) services provided on May 16, 2018 including the CPT code 93000 for an EKG.
You asked the Plan to pay for the FQHC services. You say that the records support the billed services. The Plan denied your request. The Plan says this claim was billed with 93000 which is not billable on the Prospective Payment System. A new claim without the non-billable code must be filed.
The Plan must follow Medicare rules. Medicare rules say that the professional component for EKG services, such as those described by code 93000 are not separately payable on an FQHC claim. Therefore, we decided that the Plan does not have to pay for the federally-qualified health center (FQHC) services provided on May 16, 2018 including the CPT code 93000 for an EKG.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for home blood glucose monitor (E0607) regent strips (A4253) calibrator solution/chips (A4256) lancets (A4259) and spring powered device for lancet (A4258) provided by the provider. May 29, 2019 to August 17, 2019.
You asked the Plan to pay for diabetic supplies. You say that the records provided should support the necessity of the services in dispute. The Plan denied your request. The Plan says evidence of misrepresented services.
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 and the delivery ticket documentation for the items at issue in this appeal. The record does not contain a valid delivery ticket and proof of delivery for the supplies provided in this case. The delivery ticket submitted did not include the carriers tracking number and the proof of delivery did not include an order number or details to corroborate the delivery ticket. Therefore, we decided that the Plan does not have to pay for home blood glucose monitor (E0607) regent strips (A4253) calibrator solution/chips (A4256) lancets (A4259) and spring powered device for lancet (A4258) provided by the provider. May 29, 2019 to August 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a home blood glucose monitor and supplies (E0607, A4253, A4259, A4256 and A4258) provided on July 25, 2019 through October 13, 2019.
You asked the Plan to pay for the home blood glucose monitor and supplies. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the medical records submitted upon appeal appear to have been altered. Additionally, the documentation submitted did not include an itemized shipping/billing invoice to indicate the specific supplies dispensed to the patient, 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 physician order and proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid physician order and proof of delivery for the supplies provided in this case.
Additionally, in the physician's order, the name and the NPI of the ordering physician have been altered in a manner that is not consistent with CMS guidelines. Therefore, we decided that the Plan does not have to pay for a home blood glucose monitor and supplies (E0607, A4253, A4259, A4256 and A4258) provided on July 25, 2019 through October 13, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the podiatry services rendered to the enrollee by the doctor on July 24, 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. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the podiatry services rendered to the enrollee by the doctor on July 24, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on June 4, 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 this is not a covered benefit.
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 lab services provided to the enrollee on June 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 15, 2019 by an out of network provider.
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 were rendered by a non-network provider without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on August 15, 2019 by the out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for lumbar-sacral orthosis (L0650) provided on March 19, 2019.
You asked the Plan to pay for the lumbar-sacral orthosis. You say that the lumbar-sacral orthosis is medically
necessary. The Plan denied your request. The Plan says review of claims history for this member, and a review
of the submitted documentation does not contain evidence of a prior Telemedicine or Telehealth service with
the ordering physician as required per CMS guidelines.
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 lumbar-sacral orthosis
(L0650) provided on March 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 5, 2019 by an out of network provider.
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 were rendered by a non-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 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 August 5, 2019 by the out of network provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered to the enrollee by the provider on June 12, 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 95868 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 95868 is needle electromyography; cranial nerve supplied muscles, bilateral. We find that CPT code 95868 is not supported in the medical record. Specifically, there is no clear documentation that needle electromyography was performed. 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 services rendered to the enrollee by the provider on June 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a home glucose monitor (E0607), test strips (A4253), lancets (A4259), calibrator solution (A4256), and a lancet device provided on May 28, 2019 to August 16, 2019.
You asked the Plan to pay for diabetic supplies. You say that these items should be covered. The Plan denied your request. The Plan says the delivery ticket submitted did not include the carrier's tracking number, nor did the proof of delivery include an order number or 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 physician order and 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. Specifically, the delivery ticket and the proof of delivery did not corroborate one another in regards to an order number and carrier. Therefore, we decided that the Plan does not have to pay for a home glucose monitor (E0607), test strips (A4253), lancets (A4259), calibrator solution (A4256), and a lancet device provided on May 28, 2019 to August 16, 2019.