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

We decided that the Plan does not have to pay for bilateral ankle foot orthoses (L1971) provided to the enrollee
on May 1, 2019.
You asked the Plan to pay for the orthoses. You say that the durable medical equipment is medically necessary.
The Plan denied your request. The Plan says the documentation indicates services are not necessary for
treatment of the enrollee's condition.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for the orthoses. Our reviewer says that the
enrollee does not meet criteria for the orthoses ordered. Our physician reviewer found the documentation in the
case file does not support that the requested ankle/foot orthoses were medically reasonable and necessary for
the enrollee in this case, according to the criteria established by the LCD. A physical examination of the ankles
and feet would reasonably be required to adequately assess whether the coverage criteria were met. The
documentation does not support that the ankle/foot orthoses were medically reasonable and necessary in this
case, as there is no documentation of a physical examination of the ankles and feet.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the orthoses have not been met. Therefore, we decided that the Plan does not
have to pay for bilateral ankle foot orthoses (L1971) provided to the enrollee on May 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to the out-of-network provider, for the Enrollee.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says medically necessary care is available in-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 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 to the out-of-network provider, for the Enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for crushing a stone in the urinary duct with a stent using an endoscope (52356) provided on October 3, 2019.You asked the Plan to waive the copayment forcrushing a stone in the urinary duct with a stent using an endoscope. You say that you shouldnot be liable because the procedure was not completed. You are scheduled to have another procedure done since the first procedure was not completed.The Plan denied your request. The Plan says outpatient surgery in an ambulatory surgical center has a $225 copayment.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 $225 copayment for outpatient surgery in an ambulatory surgical center. You have been asked to pay a $225 copayment for crushing a stone in the urinary duct with a stent using an endoscope. This servicefalls within the outpatient surgery in an ambulatory surgical center 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 forcrushing a stone in the urinary duct with a stent using an endoscope (52356) provided on October 3, 2019
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the BLS non-emergency ambulance service (A0428) and
ground mileage (A0425) provided on August 18, 2018.
You asked the Plan to pay for the ambulance service. You say that the hospital service was covered by you
received the bill for the ambulance and you do not believe you are responsible for full payment. The Plan
denied your request. The Plan says non-emergent services with non-contracted providers require priorauthorization
prior to services being rendered. The enrollee could have been taken by alternate transportation.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan
follows the same rules.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for the ambulance service. Our reviewer says
that this enrollee did not meet the medically necessary criteria for ambulance transport. Our physician reviewer
found the documentation does not support that other means of transport (such as stretcher van, wheelchair van,
taxi, private car, or other type of vehicle) were contraindicated. The cited reason for transport was inability to
ambulate due to Parkinson's disease. However, this could have been accommodated with transport by stretcher
or wheelchair van. The documentation does not support that the enrollee needed the expertise, services and
lifesaving and life-sustaining equipment that only a fully-equipped ambulance can provide. There was no
documented need for BLS or ALS 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 the ambulance service have not been met. Therefore, we decided that the Plan
does not have to pay for the BLS non-emergency ambulance service (A0428) and ground mileage (A0425)
provided on August 18, 2018.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee from February 26, 2019 to February 28, 2019.
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your request. The Plan says a valid treatment authorization code is required, and was not billed.
The Plan must follow Medicare rules. Medicare rules say that home health claims require a treatment authorization code. The case file did not contain a valid treatment authorization code. 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 health services provided to the enrollee from February 26, 2019 to February 28, 2019.
Appeal type: Hospice
Decision: Favorable

We decided that the Plan has to pay for physician services provided on May 17, 2019.
You asked the Plan to pay for physician services. You say that you were given five different insurance cards. You say that you didn't know you needed authorization. The Plan denied your request. The Plan says that hospice is not a covered service by Medicare.
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 Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not submit evidence that the enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore, we decided that the Plan has to pay for physician services provided on May 17, 2019.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the diagnostic mammogram and ultrasound provided on October 22, 2019.
You asked the Plan to waive the copayments for the diagnostic mammogram and ultrasound. You say that you were not aware there was a charge for an annual mammogram. The Plan denied your request. The Plan says the copayments 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 $40 copayment for each basic imaging service (general x-rays or ultrasound). You have been asked to pay a $40 copayment for the diagnostic mammogram and a $40 copayment for the ultrasound. The diagnostic mammogram and ultrasound fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The records show that the mammogram was ordered for diagnostic purposes. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the diagnostic mammogram and ultrasound provided on October 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on April 5, 2019 by the out of network provider.
You asked the Plan to pay for the office visit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
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 office visit provided on April 5, 2019 by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the specialist office visit provided on September 16, 2019.
You asked the Plan to reduce the copayment for the specialist office visit. You say that you should be paying the $5 primary care physician copayment because you see the nurse practitioner. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $35 copayment per specialist visit. The enrollee has been asked to pay a $35 copayment for the specialist office visit. The specialist office visit falls within "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows the provider is a Nephrologist.
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 reduce the copayment for the specialist office visit provided on September 16, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthosis (L1851) and suspension sleeve (L2397) provided to the enrollee on July 10, 2019.You asked the Plan to pay for the orthosis and sleeve. You say that the durable medical equipment is medically necessary.The Plan denied your request. The Plan says they were unable to discover any evidence of an established relationship between the member and the ordering physician. The Plan states there were no claims submitted for an evaluation and management service. The Plan states the review of claims history for this member, and a review of the submitted documentation does not containevidence of a prior Telemedicine or Telehealth service with the ordering physician as requiredper CMS guidelines.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the orthosis and sleeve. Our reviewer says that the enrollee does not meet criteria for the orthosis and sleeve ordered. Our physician reviewer found the documentation in the case file does not support that the requested knee orthosis and sleeve were medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. There is insufficient documentation of recent injury to, or recent surgical procedure on, the enrollee's knee, and there is insufficient credible objective documentation of joint laxity. The item coded L2397 (sleeve) is not separately payable when the base item is not covered.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 orthosis and sleeve have not been met.Therefore, we decided that the Plan does not have to pay forknee orthosis (L1851) and suspension sleeve (L2397) provided to the enrollee on July 10, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes (99291) provided on July 6, 2019 and July 11, 2019.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the medical records do not support this service.
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 99291 is not supported in the medical record. Specifically, the medical records did not contain a critical care note of 30-74 minutes for dates of service July 6, 2019 and July 11, 2019. 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 critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes (99291) provided on July 6, 2019 and July 11, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the DecisionDX- Melanoma testing provided on May 30,
2019.
You asked the Plan to pay for the DecisionDX- Melanoma testing. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered
benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.
The DecisionDX- Melanoma testing at issue in this appeal was requested solely for screening purposes.
Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not
have to pay for the DecisionDX- Melanoma testing provided on May 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on September 30, 2019 by the out-of-network provider.
You asked the Plan to pay for the office visit. 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 a covered benefit.
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 office visit provided on September 30, 2019 by the out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on July 31, 2019 by an out of network provider.
You asked the Plan to pay for an office visit. You say that these services were medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained 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 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 an office visit provided on July 31, 2019 by the out of network provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to hold you harmless for the determination of a refractive state (92015) provided on October 10, 2019.You asked the Plan to hold you harmless for the determination of a refractive state. You say that you were told to see this provider to receivea better refraction. The Plan denied your request. The Plan says that this is not a Medicare covered benefit.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). When a plan provider gives, or refers an enrollee for, a service that the enrollee reasonably believes is covered by the plan, the enrollee is held harmless and need not pay more than the plan-allowed cost-sharing for that service. Your contract with the Plan does not say in clear and accurate terms when refraction testing is covered.  We looked at your contract with the Plan.The physcician is a contract provider and an agent of the Plan. The file does not show that the Plan provided clear notice that the refraction testing would not be covered. This means that the Plan did not follow Medicare rules for disclosure of coverage information. Therefore, we decided that the Plan has to hold you harmless for the determination of a refractive state (92015) provided on October 10, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 71045) provided to the enrollee on August 12, 2019.
You asked the Plan to pay for the services. You say that the enrollee received multiple tests on this date of service. The Plan denied your request. The Plan says this is a duplicate claim line.
The Plan must follow Medicare rules. Medicare rules say that an exact duplicate for physician and other supplier claims submitted to a MAC or carrier is a claim or claim line that exactly matches another claim or claim line with respect to the above elements. We looked at the file and Medicare rules. The records show that the services at issue were billed on a duplicate claim line to services that were previously paid for the date of service in question. 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 the services (CPT 71045) provided to the enrollee on August 12, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the SNF stay provided from August 1, 2019 through August 21, 2019.
You asked the Plan to waive the copayment for the SNF stay. You say that the facility filed for extensions without advising you of a copayment. You say that if you knew of a copayment you would have left. 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 $0 copayment per day, per admission for days 1-20 and a $172 copayment per day, per admission for days 21-100. You have been asked to pay $1,315.94, which is less than the standard $1,376 copayment for the SNF stay. The SNF stay falls within the "Skilled nursing facility (SNF) care" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the SNF stay provided from August 1, 2019 through August 21, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

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 that 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 supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (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 been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from July 12, 2019 through July 19, 2019.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.