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

We decided that the Plan does not have to pay for the ankle/foot orthoses provided to the enrollee on December 26, 2019.
You asked the Plan to pay for the orthoses. The Plan denied your request. The Plan says that the billed supply code cannot be verified.
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. A physical examination of the ankles and feet would reasonably be required to adequately assess whether the coverage criteria were met. The documentation dated 12/12/19 documents no joint pain, joint swelling or joint deformities. There is no documentation of a physical examination of the ankles and feet. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for the orthoses. 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 orthoses provided to the enrollee on December 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the insertion of an intrauterine device (IUD) (58300, J7298).You asked the Plan to pay for the insertion of an IUD. You say that you were told that this would be covered.The Plan denied your request. The Plan says this is not covered under Medicare rules.The Plan must follow Medicare rules. Medicare rules say that status code N indicates a non-covered service.We find that CPT codes58300 and J7298 have a status of N, meaning they represent non-covered services.Based on this information, we decided that Medicare rules for coverage of the insertion of an IUD have not been met.Therefore, we decided that the Plan does not have to pay for the insertion of an intrauterine device (IUD) (58300, J7298).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an X-ray provided on November 25, 2019.
You asked the Plan to waive the copayment for an X-ray. You say that you disagree with the charges. The Plan
denied your request. The Plan says the claims were processed correctly and you are being charged the correct
amount.
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 $100
copayment for outpatient hospital services.
You have been asked to pay the allowed amount of $77.18, which is less than the $100 copayment for an Xray.
An X-ray falls within the outpatient hospital services benefit category. This means that you have been
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have
to waive the copayment for an X-ray provided on November 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for prosthetic devices and related supplies provided on January 2, 2020.
You asked the Plan to waive the coinsurance for prosthetic devices and related supplies. You say that you disagree with the charges because you have never been charged in the past. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
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 prosthetic devices and related supplies. You received prosthetic devices and related supplies on January 2, 2020. The total allowed amount is $313.55 and 20% of that is $62.71 You have been asked to pay the total coinsurance amount of $62.71 for prosthetic devices and related supplies. Prosthetic devices and related supplies fall within the prosthetic devices 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 for prosthetic devices and related supplies provided on January 2, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient lab work provided on December 3, 2019 by an out of network (OON) provider. You asked the Plan to pay for outpatient lab work. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the member's in-network primary care physician did not refer these services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the 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 outpatient lab work provided on December 3, 2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for x-rays (73080, 73070) provided December 16 to December 27, 2019 by provider.You asked the Plan to waive the copayment for the X-rays. You say that you were told you would not be billed.The Plan denied your request. The Plan says the correct cost sharing was 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 $15 copayment for Radiology Services. You have been asked to pay a$15 copayment for the X-rays. The X-rays fall within the Radiology Services 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 x-rays (73080, 73070) provided December 16 to December 27, 2019 by provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for an extremity study (93971) provided on October 23, 2019.
You asked the Plan to pay for the extremity study. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code 93971 has a bilateral surgery indicator of "0" which means that payment adjustment for bilateral procedures does not apply.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 93971 26 50 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code 93971 is a unilateral procedure. This service has been billed with an inappropriate modifier for bilateral procedures. Based on this information, we decided that Medicare rules for coverage of the extremity study have not been met. Therefore, we decided that the Plan does not have to pay for an extremity study (93971) provided on October 23, 2019. Please note, corrected claims should be submitted to the Plan for consideration.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Zostavax (Shingles) vaccine you received on October 22, 2019.
You asked the Plan to pay for the vaccine. The Plan denied your request. The Plan says the service is not a covered Part B drug or service.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the vaccine. Therefore, we decided that the Plan does not have to pay for the Zostavax (Shingles) vaccine you received on October 22, 2019.
Benefits for the vaccine 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the myocardial perfusion imaging (MPI) and stress test rendered on June 5, 2019.
You asked the Plan to waive the copayments for these services. You say that you disagree with the charges. The Plan denied your request. The Plan says the copayments were 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 $395 copayment for each covered nuclear medicine study and a $10 copayment for each Original Medicare covered diagnostic test or procedure.
Review of the file shows that you received MPI on June 5, 2019. You have been asked to pay a $395 copayment for these services. These services fall within the covered nuclear medicine study 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 file shows that you received a stress test on June 5, 2019. You have been asked to pay a $10 copayment for these services. These services fall within the covered diagnostic test or procedure 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 copayments for the myocardial perfusion imaging (MPI) and stress test rendered on June 5, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy services.
You asked the Plan to pre-approve the additional services. You say that this is medically necessary. The Plan
denied your request. The Plan says there was no new clinical documentation submitted to support the medical
necessity of this procedure.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.
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 the additional services. Our reviewer
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the
enrollee's condition. Our physician reviewer found the documentation does not support the need for the
requested number of physical therapy visits. You are more than 6-9 months' post stroke and has received
therapies earlier. 2 more visits to show you balance exercises and educate him are adequate. You are already
doing sit ups 300 a day and jogs. You need to practice balance activities and skills he learns in therapy
sessions. It is not accepted, specific and effective therapy for your condition of improving balance to provide
these number of requested visits. The records do not demonstrate that the unique skills of a professional
therapist are required beyond the suggested two visits to safely and effectively provide treatment, that the
services can be safely and effectively performed only by a therapist, or for physical therapy and occupational
therapy, by or under the supervision of a therapist. Lastly, the requested services are not part of a maintenance
program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design
and/or deliver a program to maintain your current condition or to prevent or slow further deterioration. The
requested in-home PT visits beyond two suggested are not 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 additional services have not been met. Therefore, we decided that the Plan
does not have to pre-approve additional physical therapy services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee brace (L1833 and L2397) provided on December 19, 2019.
You asked the Plan to pay for the knee brace. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted did not indicate the provider discussed the need for the billed supply code.
The Plan must follow Medicare rules. Medicare rules say that for any DMEPOS item to be covered by Medicare, the patient's medical record must contain sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use or replacement. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the knee brace have not been met. Specifically, the record indicates that the Plan requested documentation to validate an established relationship with the ordering physician, along with documentation of the duration of the patient's condition, clinical course (worsening or improving), prognosis, nature and extent of functional limitations, other therapeutic interventions and results, and previously purchased DME items related to the billed items. There is insufficient information to verify the billed supplies. Therefore, we decided that the Plan does not have to pay for a knee brace (L1833 and L2397) provided on December 19, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on May 8, 2018.
You asked the Plan to pay for drug test. 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 the documentation submitted does not include a valid physician order, laboratory requisition, or medical records stating exactly which tests were to be performed.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include a valid physician order or clear intent to order the specific lab services billed on this claim. Based on this information, we decided that Medicare rules for coverage of drug test have not been met. Therefore, we decided that the Plan does not have to pay for drug testing provided on May 8, 2018.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on November 4, 2019.You asked the Plan to pay for the laboratory services. You say that the doctor needed to check your liver and thyroid function after taking new medication. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.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 and the referring provider are not network providers with the Plan. The Plan did not pre-approve the laboratory services.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 laboratory services provided on November 4, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on December 5, 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 the enrollee by an out-of-network provider on December 5, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on January 4, 2020.
You asked the Plan to waive the copayment for the emergency room visit. You say that you should not be responsible for the copayment for your second emergency room visit. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
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 $90 copayment per emergency department visit. You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls within the "Emergency care" 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 the emergency room visit provided on January 4, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for EEG digital analysis (CPT 95957) provided to the enrollee on August 12, 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 CPT 95957 is inclusive in CPT 95953 from 8/7/19, 8/8/19, and 8/9/19.
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 95957 is "Digital analysis of electroencephalogram (EEG) (eg, for epileptic spike analysis)." We asked our coding reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not coded correctly. Our coding reviewer found in the absence of a Local Coverage Determination, Medicare contractors can establish their own coverage policies. In this case, the Plan uses their commercial policy for the adjudication of their Medicare claims. Their policy follows the recommendations of the American Academy of Neurology indicating CPT codes for "monitoring for identification and lateralization of cerebral seizure focus" include epileptic spike analysis. As a result, CPT code 95957 is considered included in the reimbursement of 95953 which was performed on 8/7/2019, 8/8/2019, and 8/9/2019. The commercial policy states effective May 29, 2019 "CTV will deny CPT 95957 when billed in addition to CPT 95951, 95953 or 95956. These codes for monitoring for identification and lateralization of cerebral seizure focus" already include epileptic spike analysis. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for EEG digital analysis (CPT 95957) provided to the enrollee on August 12, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a drug test provided on January 6, 2020.
You asked the Plan to pay for the drug test. The Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 did not pre-approve the drug test. 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 a drug test provided on January 6, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a drug test provided on December 4, 2019.
You asked the Plan to pay for the drug test. The Plan denied your request. The Plan says non-emergent, nonurgent
services with out-of-network providers require 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 did not pre-approve the
drug test. 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 a drug test provided on December 4, 2019.