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

We decided that the Plan does not have to pay for the glucose monitor, test strips, lancets, control solution, and lancet device provided from May 20, 2019 to August 8, 2019.
You asked the Plan to pay for the glucose monitor (E0607), test strips (A4253), lancets (A4259), control solution (A4256), and lancet device (A4258). You say that the Plan should pay this claim.The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered.Therefore, we decided that the Plan does not have to pay for the glucose monitor, test strips, lancets, control solution, and lancet device provided from May 20, 2019 to August 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on April 27, 2019. You asked the Plan to pay for the office visit. You say that you would like reconsideration as you have been in-network with the Plan since 2018. The Plan denied your request. The Plan says the services are not authorized because the rendering provider is out-of-network and the member self-directed for care.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 April 27, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on June 30, 2019. You asked the Plan to pay for ambulance response and treatment, no transport. You say that you were ignorant of the fact that Medicare places a financial penalty on individuals who refuse to take a ride in the ambulance.The Plan denied your request. The Plan says this is not a covered benefit by Medicare.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on June 30, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on June 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on May 10, 2019 and billed under code 99243.You asked the Plan to pay for code 99243. You say that this claim should be paid.The Plan denied your request. The Plan says code 99243 has a status code indicator of "I" meaning it is not valid for Medicare billing purposes.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.Medicare does not pay codes with a status indicator of "I" reported for Medicare claims. The guidelines show code 99243 was billed incorrectly. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on May 10, 2019 and billed under code 99243.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services rendered on April 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 procedure code 99152 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 99152 is moderate sedation services by physician also performing a procedure, patient 5 years of age or older, first 15 minutes.We find that CPT code 99152 is not supported in the medical record. Specifically, there is no documentation of an independent trained observer to assist with monitoring consciousness and physiological status. 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 moderate sedation services rendered on April 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on July 11, 2019.You asked the Plan to waive the copayment for the office visit. You say that you would like the plan to reconsider their decision.The Plan denied your request. The Plan says the services have been processed correctly per 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 $15 copayment for physician/practitioner services. You have been asked to pay a $15 copayment for the office visit. The office visit falls within the physician/practitioner 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 the office visit provided on July 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit (99215) provided on August 10, 2019.You asked the Plan to waive the copayment for an office visit. You say that you thought this would be included in your hospital stay.The Plan denied your request. The Plan says this processed 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 $45 copayment for for each office visit to a specialist. You have been asked to pay a $45 copayment for an office visit with a specialist. 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 foran office visit (99215) provided on August 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for diabetes outpatient self-management training services provided on June 12, 2019.You asked the Plan to pay for the diabetes outpatient self-management training services. The Plan denied your request. The Plan says non-emergent, non-urgent 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 diabetes outpatient self-management training 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 diabetes outpatient self-management training services provided on June 12, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from August 14, 2018 through August 15, 2018.You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary.The Plan denied your request. The Plan says the stay is not medically necessary.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met.Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from August 14, 2018 through August 15, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical boot/shoe, each (CPT Code L3260) provided to the enrollee on June 22, 2019.You asked the Plan to pay for the surgical boot. You say that you are separate from the hospital and you provide products to the hospital.The Plan denied your request. The Plan says this item is not a covered benefit.Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.  Records show that enrollee does not suffer from diabetic foot disease and does not wear a leg brace. Although orthotics may be appropriate for enrollee, neither Medicare nor the Plan provides coverage of orthotics for the enrollee's condition.Therefore, we decided that the Plan does not have to pay for surgical boot/shoe, each (CPT Code L3260) provided to the enrollee on June 22, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided to the enrollee by an out-of-network provider on July 8, 2019.You asked the Plan to pay for the lab 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 lab services provided to the enrollee by an out-of-network provider on July 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the pattern electroretinography (PERG) testing provided on July 2, 2019.You asked the Plan to pre-approve the PERG testing. You say that you were told that this was necessary and was not an experimental test.The Plan denied your request. The Plan says the use of this testing is not supported as medically reasonable and 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 the PERG testing. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is a 77-year-old man with a diagnosis of Pigmentary glaucoma, bilateral, mild stage. He presented on 7/12/19 for a 4 month intraocular pressure check. There were no reported vision changes at that time. His vision and pressures were deemed to be adequately controlled. Electroretinography testing is generally used to evaluate for hereditary and acquired retinal conditions. The documentation does not support that this testing was medically reasonable and necessary for the enrollee in this case.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 PERG testing have not been met.Therefore, we decided that the Plan does not have to pre-approve the pattern electroretinography (PERG) testing provided on July 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora tetanus, diphtheria toxoids and acellular pertussis vaccine (90715) provided on June 4, 2019.You asked the Plan to pay fora tetanus, diphtheria toxoids and acellular pertussis vaccine. You say that you cannot afford to pay for this out of pocket.The Plan denied your request. The Plan says coverage of this vaccine is the responsibility of your Part D benefit.In the absence of injury or direct exposure to illness, Medicare does not pay for or provide a tetanus, diphtheria toxoids and acellular pertussis vaccine. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to a tetanus, diphtheria toxoids and acellular pertussis vaccine.Therefore, we decided that the Plan does not have to pay fora tetanus, diphtheria toxoids and acellular pertussis vaccine (90715) provided on June 4, 2019.Benefits for a tetanus, diphtheria toxoids and acellular pertussis vaccinemay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics.You asked the Plan to pay for foot orthotics. You say that you were ordered to get the shoes by your doctor. You say that you have gotten the requested orthotics before.The Plan denied your request. The Plan says this item is not a covered benefit.Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.  Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition.Therefore, we decided that the Plan does not have to pay for foot orthotics.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on February 7, 2019 to February 13, 2019 by 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 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 February 7, 2019 to February 13, 2019 by out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe acute inpatient hospital care provided on February 11, 2019 to February 14, 2019 by the provider.You asked the Plan to pay foracute inpatient hospital care. You say that the services were medically necessary.The Plan denied your request. The Plan says the care received could have been provided at an observation level of care, therefore coverage criteria for inpatient admission has not been met.The Plan must follow Medicare rules.The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewersays that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found based on the medical records provided there is not sufficient evidence to show that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or observation care) would span two midnights. Care at a lower level such as observation level appears to have been appropriate.We looked atthis physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met.Therefore, we decided that the Plan does not have to pay forthe acute inpatient hospital care provided on February 11, 2019 to February 14, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient behavior health hospitalization provided to the enrollee from January 1, 2017 through January 10, 2017.
You asked the Plan to pay for inpatient behavior health hospitalization. You say that you did not obtain authorization at the time of service because you were not aware that the patient had the plan until December 22, 2017. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient behavior health hospitalization have not been met. Hospital records reveal that the member was continuously hospitalized from December 23, 2016 through January 10, 2017 for behavior health evaluation and treatment. On January 1, 2017, in the midst of the hospitalization, the member became effective for coverage under the AZ DSNP plan. Therefore, we decided that the Plan does not have to pay for inpatient behavior health hospitalization provided to the enrollee from January 1, 2017 through January 10, 2017.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on April 4, 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 physician order. The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted 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 drug testing rendered on April 4, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the PMS2 genetic testing rendered to the enrollee on April 8, 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 81317 is not covered.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for an independent laboratory; however, the file does not show that the specimen was obtained in a laboratory. Therefore, we decided that the Plan does not have to pay for the PMS2 genetic testing rendered to the enrollee on April 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for bilateral knee orthoses with suspension sleeves (L1833, L2397) provided to the enrollee on July 15, 2019.
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your request. The Plan says the enrollee has previously received the same supplies within the 5-year RUL.
The plan must follow Medicare rules. Medicare rules say that the reasonable useful lifetime of durable medical equipment is no less than five years. Replacement equipment may be granted when irreparable wear or irreparable damage is demonstrated or there has been a change in the enrollee's medical condition. We looked at the file and Medicare rules. In this instance, the submitted documentation indicates that the enrollee has received the same durable medical equipment on June 2, 2018 and June 5, 2018. These orthoses are still within the 5-year RUL and the documentation submitted does not show that the orthoses are irreparably
worn, irreparably damaged, or that the enrollee had a change in medical condition to warrant the orthosis at issue. 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 bilateral knee orthoses with suspension sleeves (L1833, L2397) provided to the enrollee on July 15, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the BLS emergency ambulance service (A0429) and ground mileage (A0425) provided on July 7, 2019.
You asked the Plan to pay for the ambulance service. You say that the services provided are unrelated to the hospice primary diagnosis. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition.
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 BLS emergency ambulance service (A0429) and ground mileage (A0425) provided on July 7, 2019.