Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home therapy services coded S9343 provided on June 26, 2019.
You asked the Plan to pay for the home therapy services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.
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 S9343 is Home therapy; enteral nutrition via bolus; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (enteral formula and nursing visits coded separately), per diem. We find that CPT code S9343 is not supported in the medical record. Specifically, this code has a status code of "I". A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for coverage of the home therapy services have not been met. Therefore, we decided that the Plan does not have to pay for the home therapy services coded S9343 provided on June 26, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an intraocular lens (IOL) for correction of nearsightedness (myopia).
You asked the Plan to pre-approve these services. You say that the current lens has shifted in your eye, causing blurred vision. The Plan denied your request. The Plan says the services are not covered.
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives an A-C IOL during cataract surgery, the enrollee will be responsible for the difference in cost between the A-C IOL and a conventional IOL. While an A-C IOL may be appropriate for you, neither the Plan nor Medicare covers the myopia-correcting feature of an IOL. Therefore, we decided that the Plan does not have to pre-approve an intraocular lens (IOL) for correction of nearsightedness (myopia).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided by an out-ofnetwork
provider on July 18, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network
deficiency for 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 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 by an out-of-network provider on
July 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of pump with oxygenator or heat exchanger (99190) provided on February 19, 2019.
You asked the Plan to pay for the assembly and operation of pump with oxygenator or heat exchanger. You say that the specialist who performed this service is independent from the surgeon and hospital The Plan denied your request. The Plan says payment of this service is included in the DRG payment.
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 pump with oxygenator or heat exchanger (99190) provided on February 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the diabetic supplies coded as E0607, A4253, A4259, A4256 and A4258 provided from June 7, 2019 to August 26, 2019.
You asked the Plan to pay for the diabetic supplies. You say that the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says the records do not support the supplies billed.
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 does not contain a valid delivery ticket and proof of delivery for the supplies provided in this case. The delivery ticket submitted did not include the carrier's tracking number, nor did the proof of delivery include an order number or details to corroborate the delivery ticket submitted. The proof of delivery is not itemized to indicate the specific supplies Therefore, we decided that the Plan does not have to pay for the diabetic supplies coded as E0607, A4253, A4259, A4256 and A4258 provided from June 7, 2019 to August 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the diabetic supplies coded as E2100, A4253, A4259, A4256 and A4258 provided from June 10, 2019 to August 29, 2019.
You asked the Plan to pay for the diabetic supplies. You say that the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says the records do not support the supplies billed.
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 does not contain a valid delivery ticket and proof of delivery for the supplies provided in this case. The delivery ticket submitted did not include the carrier's tracking number, nor did the proof of delivery include an order number or details to corroborate the delivery ticket submitted. The proof of delivery is not itemized to indicate the specific supplies. Therefore, we decided that the Plan does not have to pay for the diabetic supplies coded as E2100, A4253, A4259, A4256 and A4258 provided from June 10, 2019 to August 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral for a gastroenterology consultation from an out-of-network provider.
You asked the Plan to pre-approve the referral. You say that there are no physicians capable of handling the enrollee's medical care. The Plan denied your request. The Plan says the medical group has provided an authorization with an in-network and board certified provider.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 a referral for a gastroenterology consultation from an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the diabetic supplies coded as A4253, A4259, A4256 and A4258 provided from August 9, 2019 to October 28, 2019.
You asked the Plan to pay for the diabetic supplies. You say that the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says there is insufficient documentation to corroborate the service so that the Medicare coverage criteria has been met.
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 does not contain a valid delivery ticket and proof of delivery for the supplies provided in this case. The delivery ticket did not include the carrier's tracking number and the proof of delivery did not include an order number or details to corroborate the delivery ticket. The proof of delivery is not itemized to indicate the specific supplies. Therefore, we decided that the Plan does not have to pay for the diabetic supplies coded as A4253, A4259, A4256 and A4258 provided from August 9, 2019 to October 28, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for test strips, lancets, control solution, and batteries provided from August 17, 2019 to November 5, 2019.
You asked the Plan to pay for test 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
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 test strips,
lancets, control solution, and batteries provided from August 17, 2019 to November 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the special pump services rendered on September 9, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of X are
statutorily excluded.
The provider submitted a claim for procedure code 99190 (special pump services). This code has a status
indicator of X and no separate Medicare payment. Payment is included in the payment to the facility.
Therefore, we decided that the Plan does not have to pay for the special pump services rendered on September 9, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the colonoscopy services provided on August 12, 2019.
You asked the Plan to pay for the colonoscopy services. You say that you would like the plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network 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 colonoscopy services provided on August 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the diabetic supplies coded as A4253, A4259, A4256 and A4235 provided from August 9, 2019 to October 28, 2019.
You asked the Plan to pay for the diabetic supplies. You say that the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says the records do not support the supplies billed.
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 does not contain a valid delivery ticket and proof of delivery for the supplies provided in this case. The delivery ticket submitted did not include the carrier's tracking number, and the proof of delivery include an order number or details to corroborate the delivery ticket submitted. The proof of delivery is not itemized to indicate the specific supplies. Therefore, we decided that the Plan does not have to pay for the diabetic supplies coded as A4253, A4259, A4256 and A4235 provided from August 9, 2019 to October 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 99190) provided on August
27, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment for this
service would be included in the Part A DRG payment to the facility.
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other
than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all
necessary covered services to the beneficiary either directly or under arrangements made with outside
providers. Payment for all fees related to this service would have been included under the facility claim.
Therefore, we decided that the Plan does not have to pay for the services (CPT 99190) provided on August 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services provided on August 2,
2019.
You asked the Plan to pay for the anesthesia services. The Plan denied your request. The Plan says the billed
services 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 CPT Code Manual definition of code 99152 is Moderate sedation services provided by the
same physician or other qualified health care professional performing the diagnostic or therapeutic service that
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of
the patient's level of consciousness and physiological status.
We find that CPT code 99152 is not supported in the medical record. Specifically, the records do not indicate
an independent trained observer was present at the time of service. Based on this information, we decided that
Medicare rules for coverage of the anesthesia services have not been met. Therefore, we decided that the Plan
does not have to pay for the anesthesia services provided on August 2, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided to the enrollee on August 20, 2019.
You asked the Plan to waive the copayment for the ambulance transport. You say that this transport was medically necessary. The Plan denied your request. The Plan says that 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). The enrollee's contract with the Plan clearly says that enrollees must pay $200 copayment for Ambulance Services. The enrollee has been asked to pay $200 copayment for the ambulance transport. The ambulance transport falls within the Ambulance Services benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance transport provided to the enrollee on August 20, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on February 6, 2019 by the out of network provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by a non-network provider without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The referring provider 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 laboratory services provided on February 6, 2019 by the out of network provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy services (HCPCS S9328) provided to the enrollee from October 2, 2018 to March 19, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says this code is not payable by Medicare.
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 HCPCS code S9328 is not supported in the medical record. Specifically, this code has a status indicator of I according to the Medicare Physician's Fee Schedule. This indicates that the code is not valid for Medicare purposes. 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 home infusion therapy services (HCPCS S9328) provided to the enrollee from October 2, 2018 to March 19, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric services.
You asked the Plan to pre-approve the inpatient psychiatric services. You say that the enrollee shows homicidal
ideation, physical aggression, verbal aggression impulsiveness, hallucinations, and insomnia upon arrival to the
facility. You say that the enrollee threatened to harm himself. You say that, due to the severity of the enrollee's
psychiatric symptoms, he is unable to participate in and outpatient psychiatric treatment program. The Plan
denied your request. The Plan says there was no clinical information provided to support this level of care.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the
patient requires active treatment. The rules also say that, in order for coverage to be considered, information
must be submitted to confirm that Medicare coverage criteria have been met.
We looked at the file and Medicare rules. The case file did not include medical records. The plan provided
evidence of having made reasonable attempts to obtain this necessary documentation. Without medical records,
we are unable to confirm that Medicare coverage criteria have been met. Therefore, we decided that the Plan
does not have to pre-approve inpatient psychiatric services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement for the chiropractic services provided by out of
network provider from September 5, 2018 to September 26, 2019.
You asked the Plan to issue reimbursement for these services. You say that you have seen the provider for
chiropractic care for more than sixteen years as he has provided you with the only relief you have received
from pain and discomfort in your back and neck. The Plan denied your request. The Plan says you must receive
care from an in-network provider. Usually, the plan will not cover care from a provider who does not work
with the health plan.
The Plan must follow Medicare rules. Medicare rules say that plans can require enrollees to get care from
network providers. The contract with the Plan says that the Plan provides care from out-of-network providers
only in cases involving emergencies, out of area urgent care and pre-approved care.
The provider who rendered the services in this case is not a network provider with the health plan. Therefore,
we decided that the Plan does not have to issue reimbursement for the chiropractic services provided by the out
of network provider from September 5, 2018 to September 26, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the CT scan provided on August 30, 2019 by out of network provider
You asked the Plan to pay for a CT scan. 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 for these services. The Plan says that the referring provider, is also out-of-network.
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 CT scan provided on August 30, 2019