Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a CT scan provided on January 4, 2019.
You asked the Plan to waive the coinsurance for a CT scan. You say that you keep receiving bills with various
amounts and 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 20%
coinsurance for diagnostic radiology services.
You received a CT scan on January 4, 2019. The allowed amount is $422.20 and 20% of that is $84.44.
You have been asked to pay the total coinsurance amount of $844.44 for a CT scan. A CT scan falls within the
outpatient diagnostic tests and therapeutic services and 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 a CT scan provided on January 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit and manual spinal manipulations provided from May 21, 2019 to June 11, 2019.
You asked the Plan to pay for chiropractic services. You say that you were told by this provider that they would submit claims for payment on your behalf and that you would receive reimbursement from Medicare for the services you received. The Plan denied your request. The Plan says the denial of payment for the office evaluation is correct, because this service is not covered by Medicare or the Plan when performed by a chiropractor. The Plan also says that the deductible amounts you are being charged are correct.
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 Plan contract says that enrollees must pay $250 deductible for out-of-network covered chiropractic services. The records show that the office evaluation provided on May 21, 2019 is not manual manipulation of the spine. Therefore, this $55 office evaluation charge is not covered by Medicare or the Plan. At the time these services were provided, $0 of the $250 out-of-network deductible for 2019 had been met. The allowed amounts of the manual spinal manipulation services totals $100, resulting in a total deductible obligation of $100. Therefore, your total responsibility for these claims is $155. Therefore, we decided that the Plan does not have to pay for an office visit and manual spinal manipulations provided from May 21, 2019 to June 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on July 8, 2019 to July 15, 2019
by the out of network provider.
You asked the Plan to pay for physician services. You say that you presented your card at the facility, where
you were advised there would be no copayment. You say that you are now receiving a bill for these services.
You say that the nurse gave you incorrect information. The Plan denied your request. The Plan says no prior
authorization was 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 physician services provided on July 8, 2019 to
July 15, 2019 by the out of network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the lesion removal provided on August 8, 2019.You asked the Plan to waive the copayment forthe lesion removal. You say that this was coded as taken place at the hospital. You say that you went to the dermatology clinic, not the hospital.The Plan denied your request. The Plan says the copayment 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 $400 copayment for in-network Medicare-covered outpatient hospital surgery services.You have been asked to pay $178.21, which is less than the standard $400 copayment for the lesion removal. The lesion removal falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show that the lesion removal was billed by the hospital. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment forthe lesion removal provided on August 8, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency room services provided to the enrollee on December 9, 2018.You asked the Plan to pay foremergency room services. You say that the claim should be paid.The Plan denied your request. The Plan says during the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness starting on the date of the Hospice election until the first day of the month following the month in which Hospice is revoked or discharged.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 foremergency room services provided to the enrollee on December9, 2018
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve domiciliary or rest home visits, 25 minutes (99335 x6), domiciliary or rest home visits, 40 minutes (99336 x6), and domiciliary or rest home visits, 60 minutes (99337 x6) to be provided by an out of network provider.
You asked the Plan to pre-approve the domiciliary or rest home visits, 25 minutes, domiciliary or rest home visits, 40 minutes, and domiciliary or rest home visits, 60 minutes. You say that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide this care. Therefore, coverage criteria has not been met.
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 pre-approve 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve domiciliary or rest home visits, 25 minutes (99335 x6), domiciliary or rest home visits, 40 minutes (99336 x6), and domiciliary or rest home visits, 60 minutes (99337 x6) to be provided by the out of network provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance services.
You asked the Plan to waive the copayment for the ambulance services. You say that you want to see if the plan would pay this bill. The Plan denied your request. The Plan says you were charged this cost sharing correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for each ambulance trip. You had 1 ambulance trip(s). The Plan charged you $250 for these services. 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 ambulance services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a hospital outpatient clinic visit (G0463), and laboratory services (80053, 82728, 86704, 86706, 86709, 86803, 87340, 91200) provided on July 3, 2019 by an out of network provider.
You asked the Plan to pay for a hospital outpatient clinic visit and lab services. You are requesting the attached medical records be reviewed for medical necessity on the claim. The patient was seen for abdominal pain, blood in the stool and hematochezia. The Plan denied your request. The Plan says the member has no out of network benefits. The non-urgent services are not authorized because the practice is a non-network provider with the member's health plan, and another non-network provider with the member's health plan referred the member for services. The member self-directed. The member's network primary care physician (PCP) did not refer for services. The health 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 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 a hospital outpatient clinic visit (G0463), and laboratory services (80053, 82728, 86704, 86706, 86709, 86803, 87340, 91200) provided on July 3, 2019 by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cervical epidural steroid injection.You asked the Plan to pre-approve cervical epidural steroid injection. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services are not medically necessary.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 pre-approve cervical epidural steroid injection. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has chronic pain at the base of the skull and ear. The enrollee has tenderness over the upper spine, but no radicular pain to the shoulder or arms. The enrollee does nothave tenderness over the occipital nerves. The MRI does not show foraminal stenosis at above C3-C4. The enrollee does not have radicular symptoms. Therefore, the enrollee does not meet criteria for the requested services.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of cervical epidural steroid injection have not been met.Therefore, we decided that the Plan does not have to pre-approvecervical epidural steroid injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for diabetic supplies provided to the enrollee from August 3,
2019 to October 22, 2019.
You asked the Plan to pay for the supplies. You say that this should be paid for. The Plan denied your request.
The Plan says the billed supply codes cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, the definition of the denied codes is:
HCPCS A4253:
Blood glucose test or reagent strips for home blood glucose monitor, per 50 strips
HCPCS A4259:
Lancets, per box of 100
HCPCS A4256:
Normal, low, and high calibrator solution/chips
HCPCS A4235:
Replacement battery, lithium, for use with medically necessary home blood glucose monitor owned by patient,
each.
We find that the denied codes are not supported in the medical record. Specifically, the delivery ticket
submitted did not include the carrier's tracking number. The proof of delivery also did not include an order
number or details to corroborate the delivery ticket submitted. Based on this information, we decided that
Medicare rules for coverage of the supplies have not been met. Therefore, we decided that the Plan does not
have to pay for diabetic supplies provided to the enrollee from August 3, 2019 to October 22, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services provided on May 17, 2019.
You asked the Plan to pay for ambulance services. You say that the services are unrelated to hospice diagnosis. The Plan denied your request. The Plan says the Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation.
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 ambulance services provided on May 17, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe resin based composite (D2331) provided on September 24, 2019.You asked the Plan to pay forthe dental service. You say that the provider's office advised that they were in network with your plan.The Plan denied your request. The Plan says services are only covered when they are received by a participating provider. The Plan also says the provider in this case is not a participating provider.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the resin based composite is not covered when received out of network.Therefore, we decided that the Plan does not have to pay forthe resin based composite (D2331) provided on September 24, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the custom fabricated abutment and abutment supported porcelain/ceramic crown provided on August 13, 2019.You asked the Plan to pay for the abutment and abutment supported crown. You say that you have always taken good care of your teeth. You also say that you do not think that having implants put in was an unnecessary or unreasonable request.The Plan denied your request. The Plan says these implant services are not covered benefits under your plan.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay for the custom fabricated abutment and abutment supported porcelain/ceramic crown provided on August 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided on August 22, 2019.
You asked the Plan to waive the copayment for an office visit. You say that you disagree with the charges because this was your annual wellness visit. 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 $15 copayment for primary care provider visits. The medical records show that you received services beyond an annual wellness visit on August 22, 2019. Therefore, you are responsible to pay the $15 copayment. You have been asked to pay a $15 copayment for an office visit. An office visit falls within the physician/practitioner services, including doctor's office visits 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 office visit provided on August 22, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for breast tomosynthesis (77062) provided on October 14, 2019.You asked the Plan to pay for the breast tomosynthesis. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says Medicare guidance says 77062 has a status code of I.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 77062 is not supported in the record. Specifically, per the 2019 Physician Fee Schedule, 77062 has a status indicator of I. This means that 77062 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the breast tomosynthesis have not been met. Therefore, we decided that the Plan does not have to pay for breast tomosynthesis (77062) provided on October 14, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fortest strips, lancets, control solution, and batteries provided on August 24, 2019.You asked the Plan to pay fortest strips (A4253), lancets (A4259), control solution (A4256), and batteries (A4235). 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 itemsat 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 fortest strips, lancets, control solution, and batteries provided on August 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for diabetic testing supplies provided on August 19 -November 7, 2019.You asked the Plan to pay forthe diabetic testing supplies. You say that  The Plan denied your request. The Plan says the delivery ticket is not sufficient to support the billed services in dispute.The Plan mustfollow 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. The proof of delivery documentation provided does not include the carrier's tracking number or an order number. The USPS trackingdocument number is not referenced on any itemized document that specifies the supplies.Therefore, we decided that the Plan does not have to pay fordiabetic testing supplies provided on August 19 -November 7, 2019
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued SNF services for the enrollee.
You asked the Plan to pre-approve continued services. You say that the enrollee's condition is too unstable to return home without proper medical supervision. The Plan denied your request. The Plan says the enrollee does not require skilled nursing or therapy services on a daily basis.
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. The file shows that continued SNF care beyond January 22, 2020 was requested. 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 continued services. Our physician reviewer found that the enrollee's current level of function is ambulating 150-200 feet with a wheeled walker with supervision, supervision with oral hygiene, feeding, dressing, and toilet transfers, supervision with sit to stand, supervision/contact guard assist with bed mobility, contact guard assist with transfers. There are no noted daily skilled complex nursing needs. She is ambulating household distances and requires little assistance with mobility and transfers. While she may benefit from continuing physical and occupational therapy, the records do not support the need for daily therapy.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services for the enrollee.