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

We decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650) provided to the enrollee on February 1, 2018.You asked the Plan to pay for the orthosis. 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 orthere 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 September 20, 2016. This orthosis is still within the 5-year RUL and the documentation submitted does not show that the orthosis is 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 orthosis have not been met.Therefore, we decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650) provided to the enrollee on February 1, 2018.
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 24, 2019 to August 12, 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 24, 2019 to August 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nursing facility care (99308) provided on July 2, 2019 by out of network provider.
You asked the Plan to pay for nursing facility care. You say that this was a necessary service. The Plan denied your request. The Plan says this service was 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 nursing facility care (99308) provided on July 2, 2019 by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided to the enrollee out of network on February 14, 2019.You asked the Plan to pay for this 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 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 physician services provided to the enrollee out of network on February 14, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on September 9, 2019.
You asked the Plan to waive the copayment for the ambulance transport. You say that you should not have to pay this because you did not want to be transported. The Plan denied your request. The Plan says that the claim 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 $250 copayment for one-way trip by ground or air ambulance. You have been asked to pay a $250 copayment for the ambulance transport. The ambulance transport falls within the one-way trip by ground or air ambulance 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 ambulance transport provided on September 9, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the imaging services provided on to the enrollee on March 23, 2019 by out of network provider. You asked the Plan to pay for this 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 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 to the enrollee on March 23, 2019 by an out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for spring powered device for lancets (A4258) blood glucose/reagent strips (A4253) lancets (A4259) calibrator solution/chips (A4256) provided May 13, 2019 to August 1, 2019.You asked the Plan to pay for the blood glucose monitor supplies. You say that the records provided should support the necessity of the services in dispute.The Plan denied your request. The Plan says evidence of misrepresented services.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 deliver ticket or valid 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 did not include an order number or details to corroborate the delivery ticket submitted.Therefore, we decided that the Plan does not have to pay for spring powered device for lancets (A4258) blood glucose/reagent strips (A4253) lancets (A4259) calibrator solution/chips (A4256) provided May 13, 2019 to August 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora visual field examination (92083) and diagnostic imaging of the optic nerve of the eye (92133) provided on February 19, 2019 by out of network provider.You asked the Plan to pay fora visual field examination and diagnostic imaging of the optic nerve of the eye. You say that this is an incorrect denial. You say the provider has been in-network with the plan since December 2016.The Plan denied your request. The Plan says the member has no out-of-network benefits. The non-urgent services were not authorized because the physician is a non-network provider with the member's health plan, and the member self-directed. The member's network primary care physician (PCP) did not refer for services. The health plan requires utilization of network providers when possible and available and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case 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 fora visual field examination (92083) and diagnostic imaging of the optic nerve of the eye (92133) provided on February 19, 2019 by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora facet joint injection (64495) provided on May 13, 2019.You asked the Plan to pay fora facet joint injection. You say that the medical records show this procedure is supported.The Plan denied your request. The Plan says there is insufficient documentation to corroborate the services.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 64495 is injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; third and any additional level(s) (List separately in addition to code for primary procedure).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 a facet joint injection. Our reviewer says that CPT code 64495 is not supported. Our physician reviewer found according to CPT rules, 64493-64495 are reported for the number of facet joints treated. The facet joint is formed where 2 vertebral segments meet. The medical record does not contain evidence that a third facet joint was injected during this episode of care.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a facet joint injection have not been met.Therefore, we decided that the Plan does not have to pay fora facet joint injection (64495) provided on May 13, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0673).You asked the Plan to pay for a pneumatic compression device. You say that the device is necessary to prevent deep vein thrombosis.The Plan denied your request. The Plan says the pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery.The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0673) is a preventive service.We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage.Therefore, we decided that the Plan does not have to pay fora pneumatic compression device (E0673).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay fora corneal transplant (65730) provided on January 14, 2019.You asked the Plan to pay fora corneal transplant. You say that the code is supported and was medically necessary.The Plan denied your request. The Plan says the use of this CPT code is not supported by the records.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 65730 is keratoplasty (corneal transplant); penetrating (except in aphakiaor pseudophakia).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 a corneal transplant. Our reviewer says that CPT code 65730 is not supported. Our physician reviewer found the procedure note states that a keratoplasty in pseudophakia was performed. According to CPT rules, there is a more specific code for this procedure.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a corneal transplant have not been met.Therefore, we decided that the Plan does not have to pay fora corneal transplant (65730) provided on January 14, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 13, 2019 by out of network provider.
You asked the Plan to pay for the medical services. You say that this was medically necessary care which could not be delayed to obtain authorization. The Plan denied your request. The Plan says this non-emergency visit was provided without authorization. The enrollee is in an out of network facility and no network provider referred for this service. There are network providers who could have furnished this 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 August 13, 2019 by out of network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on August 13, 2019 by an out of network provider.You asked the Plan to pay foran outpatient surgery. You say that you would like this claim reprocessed and approved for payment because these services were medically necessary.The Plan denied your request. The Plan says no prior authorization was obtained. The referring doctor 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 onlyin 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 forthe medical services provided on August 13, 2019
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing provided on July 19, 2019 by out of network provider.You asked the Plan to pay for the drug 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 when provided by an out-of-network 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 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 drug testing provided on July 19, 2019 by out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic screening testing provided on May 12, 2019.You asked the Plan to pay for genetic tests. You say that you are appealing with records.The Plan denied your request. The Plan says the denial of payment for these services is correct, because these tests were ordered by telemedicine which is a Medicare-prohibited action.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay for genetic screening testing provided on May 12, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe surgical services rendered to the enrollee by the provider on July 24, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure codes 19380-50-78 and 15770-78-51 are 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 19380 is revision of reconstructed breast. The definition of code 15770 is graft; derma-fat-fascia.We find that CPT codes 19380 and 15770 are not supported in the medical record. Specifically, the operative report does not contain documentationof revision of a reconstructed breast to support code 19380 or documentation of a derma-fat-fascia graft for code 15770. 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 forthe surgical services on July 24, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe removal of impacted earwax, unilateral, provided on June 22, 2019 by out of network provider,"the provider" You asked the Plan to pay forthe surgical services. The Plan denied your request. The Plan says authorization was not obtained before the servicewas provided to the enrollee. The Plan says that the enrollee's primary care physician did not refer them for the service. The Plan also says the services were not urgent or emergent.Medicare rules say that plans can require enrollees to get care fromnetwork 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 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 forthe removal of impacted earwax, unilateral, provided on June 22, 2019 by out of network provider, "the provider".
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the 2 home visits provided by the out of network provider.
You asked the Plan to pay for the practitioner services. You say that you are in the process of becoming contracted with the Plan. The Plan denied your request. The Plan says authorization was not obtained before the service was provided to the enrollee. The Plan says the enrollee's primary care physician did not refer them for the service. The Plan also says the service was not urgent or emergent.
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 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 2 home visits provided by the out of network provider.