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

We decided that the Plan does not have to pay for the home health services provided to the enrollee from August 28, 2019 to August 30, 2019.You asked the Plan to pay forhome health services. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says report of the FIPS code is required to identify the county where the services were rendered. The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered.We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the submitted claim does not include the required FIPS code.Therefore, we decided that the Plan does not have to pay forthe home health services provided to the enrollee from August 28, 2019 to August 30, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ER visit provided on January 1, 2020.
You asked the Plan to waive the copayment for the ER visit. You say that you thought you were covered for
everything. You say that if you knew you would be charged, you would have gone to the VA. 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 $120
copayment for emergency care.
You have been asked to pay a $120 copayment for the ER visit. The ER visit falls within the "Emergency care"
benefit category. The records show that you were treated in the ER. 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 ER visit provided on January 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee braces and sleeves (L1833 RT KX, Li833, LT KX,
L2397 RT KX and L2397 LT KX) provided on December 16, 2019.
You asked the Plan to pay for the knee braces and sleeves. You say that you would like reconsideration based
on the records submitted. The Plan denied your request. The Plan says the documentation submitted did not
indicate the provider discussed the need for the billed supply code.
The Plan must follow Medicare rules. Medicare rules say that for any DMEPOS item to be covered by
Medicare, 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 and for the frequency of use or
replacement.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the knee braces and sleeves have not been met. Specifically, the record indicates that the Plan
requested documentation to validate an established relationship with the ordering physician, along with
documentation of the duration of the patient's condition, clinical course (worsening or improving), prognosis,
nature and extent of functional limitations, other therapeutic interventions and results, and previously
purchased DME items related to the billed items. There is insufficient documentation to verify the billed
supplies. Therefore, we decided that the Plan does not have to pay for knee braces and sleeves (L1833 RT KX,
Li833, LT KX, L2397 RT KX and L2397 LT KX) provided on December 16, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment for the physician visit provided on January 5, 2020.
You asked the Plan to waive the copayment for the physician visit. You say that the doctor came to see you in the emergency room. You say that the visit should not be individualized per physician. The Plan denied your request. The Plan says that the copayment applied correctly.
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. There were no records submitted to support that the physician visit was separate from an emergency room visit. Therefore, we decided that the Plan has to waive the copayment for the physician visit provided on January 5, 2020.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the compressor provided on October 24, 2019 by an out of
network provider.
You asked the Plan to pay for the compressor. You say that the Plan should pay this claim. The Plan denied
your request. The Plan says prior authorization was not requested.
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 compressor provided on October 24, 2019 by
an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for thoracoscopy (32606) provided on November 18, 2019.
You asked the Plan to pay for the thoracoscopy. You say that you would like reconsideration because this was a return trip to the operating room on the same date as the initial injury. The Plan denied your request. The Plan says a 0, 10 or 90-day post-operative procedure was not reported during its applicable post-operative period.
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 32606 is not supported in the record. Specifically, without documentation of the initial procedure, we are unable to substantiate the use of modifier 78. Based on this information, we decided that Medicare rules for coverage of the thoracoscopy have not been met. Therefore, we decided that the Plan does not have to pay for thoracoscopy (32606) provided on November 18, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory work provided on December 5, 2019.
You asked the Plan to waive the copayment for the laboratory work. You say that the testosterone testing was a part of your annual wellness visit. You say you should not have a copayment. 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). Your contract with the Plan clearly says that you must pay a $5 copayment for diagnostic lab services and diagnostic procedures and tests (per day, per facility). You have been asked to pay a $5 copayment for the laboratory work. The laboratory work falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the laboratory work provided on December 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forphysician services provided to the enrollee on November 9, 2019.You asked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says the enrollee did not have prior authorization for 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 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 service 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 forphysician services provided to the enrollee on November 9, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an ultrasound (76536) provided in a hospital on December 27, 2019.
You asked the Plan to waive the deductible for an ultrasound. You say that you don't understand why there is not an insurance payment for this service. The Plan denied your request. The Plan says your deductible applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $500 deductible. You have been asked to pay $112.50 towards your annual deductible. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible. This cost sharing is a contractual obligation that had not been met at the time an ultrasound was received on December 27, 2019. Therefore, we decided that the Plan does not have to waive the deductible for an ultrasound (76536) provided in a hospital on December 27, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the Inogen One G5 Portable oxygen concentrator on November 4, 2019.
The enrollee asked the Plan to pay for the Inogen One G5 Portable oxygen concentrator. The enrollee said that the Plan should pay for the portable oxygen concentrator because the doctor did not follow protocol. The Plan denied the request. The Plan says only rented oxygen equipment is eligible for coverage.
The Plan must follow Medicare rules. Medicare rules say that only rented oxygen equipment is eligible for coverage.
We looked at the file and Medicare rules. Purchased oxygen equipment is statutorily non-covered by Medicare. Based on this information, we decided that Medicare rules for coverage of the Inogen One G5 Portable oxygen concentrator have not been met. Therefore, we decided that the Plan does not have to pay for the Inogen One G5 Portable oxygen concentrator purchased on November 4, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on January 13, 2020.You asked the Plan to waive the copayment for the emergency room visit. You say that you never saw the doctor or called back to the emergency room. You say you left and were in the waiting room the whole time. 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). Your contract with the Plan clearly says that you must pay a $120 copayment for emergency care. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $120 copayment for the emergency room visit.You have been asked to pay a $114.43 copayment for the emergency room visit. The emergency room visit falls within the "Emergency care" benefit category. The medical record shows you were seen in the emergency room triage department.This means that you have been asked to pay the correct amount based on your contract with the Plan. Thiscost 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 emergency room visit provided on January 13, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that on the date of service you had a seizure while your occupational therapist was with you. The therapist helped you to your bed and your care giver gave you your seizure medication. You say that you specifically asked the therapist not to call 911 however the therapist did anyway. You stated that the EMT's arrived shortly after and took your vitals. You say that you declined transportation because after you took your medication the seizures had stopped. The Plan denied your request. The Plan says these services are not a covered benefit.
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 September 3, 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 the ambulance services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe subsequent nursing facility care (99309) rendered by the out of network (OON) provideron December 13, 2019.You asked the Plan to pay forthese services. You say that your company has an exclusion contract with the facility;therefore,your doctors are the only providers who will treat the patients for primary care.The Plan denied your request. The Plan says the services were provided 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 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 servicesat issue. We found no exception that would require the Plan to pay for theseservices.Therefore, we decided that the Plan does not have to pay forthe subsequent nursing facility care (99309) rendered by the out of network (OON) provideron December 13, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an ambulance trip provided on January 7, 2020.
You asked the Plan to waive the deductible for an ambulance trip. You say that you were never told that you would owe anything for the trip. 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. Your contract with the Plan says that there is a $750 deductible for ambulance services. You received an ambulance trip on January 7, 2020. The record shows that you had only paid $464.75 toward the $750 deductible prior to receiving the services. Therefore, you are responsible to pay the allowed amount of $229.48. The item or service you asked the Plan to waive the deductible for falls within the benefit category ambulance services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible for ambulance services. This cost sharing is a contractual obligation that had not been met at the time an ambulance trip was received on January 7, 2020. Therefore, we decided that the Plan does not have to waive the deductible for an ambulance trip provided on January 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the portable oxygen concentrator purchased on March 28, 2019.
You asked the Plan to pay for the portable oxygen concentrator. The Plan denied your request. The Plan says that Medicare guidelines say that purchased oxygen is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that purchased oxygen equipment is statutorily non-covered. Therefore, we decided that the Plan does not have to pay for the portable oxygen concentrator purchased on March 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for office visits, X-Ray services, and ultrasound therapy provided by a chiropractor from November 27, 2019 to December 2, 2019.
You asked the Plan to pay for chiropractic services. You say that this treatment was better than going to the emergency room, and the Plan representative said they would pay for 50% of the bill. The Plan denied your request. The Plan says the denial of payment for these services is correct, because these services are not covered when performed by a chiropractor.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for office visits, X-Ray services, and ultrasound therapy provided by a chiropractor from November 27, 2019 to December 2, 2019.
Your complaint regarding receiving inaccurate information about the Plan's coverage for these services is considered to be a grievance. Please contact the Plan for more information about your grievance.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the ophthalmology services provided on December 10, 2019 by an out of network (OON) provider. You asked the Plan to pay for the ophthalmology services. You say that the records provided should support the necessity of the service in dispute. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. The plan says that non-emergent services with non-contracted providers require prior-authorization prior to services being rendered. 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 ophthalmology services provided on December 10, 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 a second annual exam received on December 27, 2019.
You asked the Plan to pay for the second exam. You say that this should be paid for. The Plan denied your request. The Plan says the benefit was exhausted.
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 99397 is "Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient." We find that CPT code 99397 is not supported in the medical record. Specifically, the file shows that this is the second annual exam received during the 2019 calendar year. The first exam happened on 10/15/19. Plan and Medicare guidelines disallow a second exam. Based on this information, we decided that Medicare rules for coverage of the second exam have not been met. Therefore, we decided that the Plan does not have to pay for a second annual exam received on December 27, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory test provided on September 4, 2019.You asked the Plan to pay for the laboratory test. The Plan denied your request. The Plan says the enrollee must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.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 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 laboratory test provided on September 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit (99328) and advanced care planning (99497) provided on July 9, 2019 by an out of network (OON) provider. You asked the Plan to pay for a domiciliary or rest home visit and advanced care planning. You say that these services should be covered. The Plan denied your request. The Plan says these 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 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 domiciliary or rest home visit (99328) and advanced care planning (99497) provided on July 9, 2019 by an out of network (OON) provider.