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

We decided that the Plan does not have to pay for the ultrasound rendered on November 23, 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 were incorrectly billed. The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis code. We looked at the file and Medicare rules. The file shows that procedure code 76882-26-RT was billed with mismatched diagnosis codes that do not match the laterality for the services. 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 ultrasound rendered on November 23, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for subsequent annual wellness visit (G0439) annual physical exam (99397) routine ECG with at least 12 leads (93010) and colorectal cancer screening; fecal occult blood test (G0328) provided January 15, 2019. You asked the Plan to waive the copayment for the office visit. You say that this claim originally processed with $0 cost share an you believe you owe $0. The Plan denied your request. The Plan says the claim initially processed with $0 obligation due to a processing error and 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 $0 copayment for an annual physical by your primary care provider. If during the physical exam, you also receive services to treat a medical condition, you will be expected to pay $10 copayment for the additional Medicare covered services, for Physician/Practitioner services, including doctor's office visits. You have been asked to pay $9.26 for the office visit. The 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 subsequent annual wellness visit (G0439) annual physical exam (99397) routine ECG with at least 12 leads (93010) and colorectal cancer screening; fecal occult blood test (G0328) provided January 15, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the Group 2 power operated vehicle purchased on July 18, 2019. You asked the Plan to reimburse you for the Group 2 power operated vehicle. You say that the Plan should reimburse you for the scooter. The Plan denied your request. The Plan says the scooter you have purchased has features not needed for use in the home and therefore not reasonable and necessary. The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. Group 2 POVs are not covered by Medicare or the Plan. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to reimburse you for the Group 2 power operated vehicle purchased on July 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on December 20, 2019 by an out of network (OON) 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 an out-of-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 December 20, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 10, 2019 by an out of network (OON) provider. You asked the Plan to pay for these services. You say that you were not aware that the provider was not covered. The Plan denied your request. The Plan says the services were rendered by an out-of-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 October 10, 2019 by an out of network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered from July 25, 2019 to July 31, 2019. You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claims were not billed correctly. The Plan must follow Medicare rules. The rules say that home health claims must be billed with a G code and one of three Q codes. We looked at the file and Medicare rules. The claims were not billed with the required Q code. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the home health services rendered from July 25, 2019 to July 31, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on December 2, 2019. You asked the Plan to pay for the laboratory services. 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 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 December 2, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay additionally for the eyeglasses purchased on September 3, 2019. You asked the Plan to pay additionally for the eyeglasses. You say that you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you purchased eyewear that costs a total of $409. The Plan says your eyewear benefit of $150 was exhausted with this purchase. The Plan says the full $150 benefit was applied to your trifocal eyeglass lens. The Plan says you are responsible for the difference once the $150 benefit is applied. Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file and the Plan's rules. The Plan's contract clearly allows up to $150 towards your eyewear benefit. The file shows that the Plan applied your $150 benefit allowance towards your eyewear purchased on September 3, 2019. The contract clearly shows that you are responsible to pay the difference. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay additionally for the eyeglasses purchased on September 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump with oxygenator or heat exchanger (99190) provided on December 10, 2019. You asked the Plan to pay for the assembly and operation of a pump with oxygenator or heat exchanger. You say that this was a necessary service.The Plan denied your request. The Plan says payment for this service is included in the DRG. The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that CMS designates to be "inpatient-only" services. These services have an OPPS status indicator of "C" in the OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule. The service at issue in this appeal was billed with CPT code 99190. This code is listed with a status indicator of "C" on Addendum B of the 2019 OPPS/ASC final rule. This means the service has been designated as "inpatient only", and therefore must be billed as part of an inpatient admission. Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump with oxygenator or heat exchanger (99190) provided on December 10, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. You asked the Plan to pre-approve the LTACH services. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where the enrollee is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services (01992) provided on November 13, 2018. You asked the Plan to pay for anesthesia services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says anesthesia codes will only be reimbursed to anesthesia providers. The Plan must follow Medicare rules. Medicare rules say that payment shall be made for reasonable and necessary medical or surgical services furnished by CRNAs if they are legally authorized to perform these services in the State in which the services are furnished. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of anesthesia services have not been met. Specifically, in the state of Texas, a certified registered nurse anesthetist does not possess independent authority to administer anesthesia without delegation by a physician. This anesthesia code was billed with a modifier (QZ) indicating Certified Registered Nurse Anesthetist (CRNA) without medical direction by a physician. Therefore, we decided that the Plan does not have to pay for anesthesia services (01992) provided on November 13, 2018.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the Shingrix vaccine provided on November 15, 2019. You asked the Plan to pay for the Shingrix vaccine. You say that you did not know that this needed to be administered by a pharmacy in order to qualify for payment. The Plan denied your request. The Plan says the vaccine in dispute is not covered under the Part B medical benefits. The Plan says that the enrollee should contact his Part D plan sponsor for information regarding coverage of this vaccine and the reimbursement process. In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Shingrix 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 Shingrix vaccine. Therefore, we decided that the Plan does not have to pay for the Shingrix vaccine provided on November 15, 2019. Benefits for the Shingrix 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the Zostavax vaccine provided on January 2, 2020. You asked the Plan to pay for the Zostavax vaccine. You say that the Plan denied your request. The Plan says this is not a covered Part B drug or service and cannot be paid by Medicare Part B. The Plan says that the enrollee should seek coverage through their part D coverage. In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Zostavax 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 Zostavax vaccine. Therefore, we decided that the Plan does not have to pay for the Zostavax vaccine provided on January 2, 2020. Benefits for the Zostavax 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for a vaccine for tentanus, diphtheria toxoids and acellular pertussis provided on December 9, 2019. You asked the Plan to pay for the vaccine. You say that you were told you needed this vaccination so that you could visit with your newborn grandchild. The Plan denied your request. The Plan says the vaccine in dispute is not covered under regular Medicare Part B and cannot be covered under the enrollee's part B health care plan. 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 a vaccine for tentanus, diphtheria toxoids and acellular pertussis provided on December 9, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the lab services you received on November 19, 2019. You asked the Plan to waive the copay for the lab services. You say that the labs were part of your annual routine physical. The Plan denied your request. The Plan says the copay was applied based on your plan benefits. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 copay per visit for lab tests. You have been asked to pay a $10 copay for the lab services. The labs fall within the outpatient diagnostic tests benefit category. Lab services are not included in the annual exam 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 copay for the lab services you received on November 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on October 16, 2019. You asked the Plan to waive the copayment for a specialist visit. You say that you feel that the services do not warrant a copayment. 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 $30 copayment for primary care provider visits. You have been asked to pay a $30 copayment for a specialist visit. A specialist 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 a specialist visit provided on October 16, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care, nail debridement, and paring or cutting of a benign lesion provided on December 10, 2019. You asked the Plan to pay for the practitioner services. You say that the enrollee has authorization for all care at the facility including consultations. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the members coverage before rendering services and to know proper billing procedures for a Medicare Advantage member 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 subsequent nursing facility care, nail debridement, and paring or cutting of a benign lesion provided on December 10, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on March 19, 2019. You asked the Plan to pay for the laboratory services. 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 and the referring provider are not network providers with the Plan. 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 laboratory services provided on March 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for lower extremity orthotics (L1833, L2397) provided December 4, 2019. You asked the Plan to pay for the orthotics. You say that the items were medically necessary. The Plan denied your request. The Plan says the records do not support the items billed. The Plan must follow Medicare rules. Medicare rules say that 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. We looked at the file and Medicare rules. The records provided include office notes and a delivery ticket. The records do not include discussion with the provider over the need of the orthotic devices. Based on this information, we decided that Medicare rules for coverage of the orthotics have not been met. Therefore, we decided that the Plan does not have to pay for lower extremity orthotics (L1833, L2397) provided December 4, 2019.