Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code 93000 provided on August 28, 2019.
You asked the Plan to pay for CPT code 93000. You say that you would like the plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. Medicare payment rules say procedure codes that are incorrectly reported with other procedure codes as a result of the misuse of the column two code with the column one code are not payable as there are limited circumstances when the column two code may be reported on the same date of service as the column one code. Therefore, we decided that the Plan does not have to pay for CPT code 93000 provided on August 28, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis (L1833, L2397) provided July 11, 2019. You asked the Plan to pay for the orthosis. You say that the orthosis was medically necessary.The Plan denied your request. The Plan says the same orthosis was already provided within the past 2 years, so a replacement is not covered under Medicare rules. Additionally, a written order detailing the need for replacement due to loss or irreparable damage was not submitted.The Plan must follow Medicare rules. Medicare rules say that the reasonable useful lifetime for the Orthosis at issue is 2 years. An orthosis was already provided within the past 2 years. A new orthosis is considered non-covered. A new written order detailing the need for replacement was not provided to the health plan.We looked at the file and Medicare rules. 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 knee orthosis(L1833, L2397) provided July 11, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0483 provided to the enrollee on April 26, 2019.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 billed are not supported by the documentation.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 G0483 is Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed.We find that CPT code G0483 is not supported in the medical record. Specifically, the documentation submitted did not include a valid physician order/lab requisition or medical records (signed by the ordering physician); therefore,the billed code cannot be verified.Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay forthe drug testing coded G0483 provided to the enrollee on April 26, 2019
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for Radiology Services (71045) provided June 28, 2019. You asked the Plan to pay for the radiology services. You say that the services were medically necessary.The Plan denied your request. The Plan says services should be billed to Original Medicare as the enrollee elected their hospice benefits.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay for Radiology Services (71045) provided June 28, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe mastopexy coded 19316 and the revision of reconstructed breast coded 19380 provided on May 10, 2019.You asked the Plan to pay forthe mastopexyand the revision of reconstructed breast. 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 supported by the documentation.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 codes 19316 and 19380 are not supported in the medical record. Specifically, the operative report did not include documentation of a mastopexy. Also, the operative report did not include documentation of a revision of reconstructed breast. Based on this information, we decided that Medicare rules for coverage of the mastopexy and the revision of reconstructed breast have not been met. Therefore, we decided that the Plan does not have to pay forthe mastopexy coded 19316 and the revision of reconstructed breast coded 19380 provided on May 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for outpatient hospital clinic services received
by the enrollee.
You asked the Plan to waive the copayments for the services. You say that you were not aware of this fee, and
you disagree with it. The Plan denied your request. The Plan says the copayments were applied correctly
according to your benefits and the services rendered.
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 $25
copayment for specialist office visits.
You have been asked to pay a $25 copayment for each of the visit. You have also been asked to pay an
additional $275 copayment for the visit, plus $221.41 (the allowed amount, less than $275). The services fall within the specialist office visits/outpatient hospital services benefit
category. This means that you have been asked to pay the correct amount based on your contract with the Plan.
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we
decided that the Plan does not have to waive the copayments for outpatient hospital clinic services received by the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on April 1, 2018 by out of network provider, "the doctor".You asked the Plan to pay forthe medical services. You say that the claim should be paid.The Plan denied your request. The Plan says the enrollee does not have out-of-network benefits.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 forthe medical services provided on April 1, 2018 by out of network provider, "the doctor".
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from May 9, 2019 through May 13, 2019.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you are being charged for incorrect hospital stay dates and that you should not have to pay a copayment because you did not receive adequate care at the hospital. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received inpatient hospital care from May 9, 2019 through May 13, 2019. You were asked to pay a $275 copayment per day from May 9, 2019 through May 12, 2019, days 1-4 of your inpatient hospital care. You were discharged on May 13, 2019 and there was no copayment charge for the day of discharge. Per your contract there is a $275 copayment per day required for days 1-6. 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 inpatient hospital care provided from May 9, 2019 through May 13, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay forthe acute inpatient hospital care provided July 31, 2019 to August 7, 2019.You asked the Plan to pay foracute inpatient hospital care. You say that inpatient level of care was medically necessary.The Plandenied your request. The Plan says that services could have been provided on an outpatient basis.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 record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital 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 forthe acute inpatient hospital care provided July 31, 2019 to August 7, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) and a knee orthosis with suspension sleeve (L1851,L2397) provided to the enrollee on February 13, 2019.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 documentation does not indicate services are necessary for treatment of the enrollee's condition.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 fora lumbar-sacral orthosis (L0650) and a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on February 13, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on June 11, 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 progress notes are needed in order to determine the clinical utility of the testing.The Plan must follow Medicare rules.Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not medically reasonable or necessary. Our physician reviewer found the clinical documentation in the case file is limited to the Infectious Disease Test Requisition Form, and the results of the testing. The available documentation is insufficient to demonstrate that the Real-time PCR testing was medically reasonable and necessary for the enrollee in this case. It has not been demonstrated that this testing would impact the management and health of this enrollee.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 services have not been met.Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on June 11, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from July 2, 2019 through July 4, 2019.
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 2, 2019 through July 4, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hyperthermia treatment provided on October 10, 2018 by out of network provider.

You asked the Plan to pay for the hyperthermia treatment. You say that the enrollee was recommended to this provider by her treating oncologist who is in-network with the Plan. The Plan denied your request. The Plan says the out of network provider failed to contact the plan to obtain authorization for these scheduled, non-emergent services. This is not covered under the enrollee's 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 did not pre-approve the item/service at issue. There is no evidence that the enrollee has a cancer for which this treatment can be covered by Medicare, nor that this is being provided in conjunction with radiation therapy as required. 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 hyperthermia treatment provided on October 10, 2018 by out of network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe hepatobiliary system imaging provided on August 13, 2019.You asked the Plan to waive the copayment forthe hepatobiliary system imaging. You say that you were informed you had no financial requirements. You say that you should not have to pay since you were not informed.The Plandenied 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 Planclearly says that you must pay $300 for Medicare-covered advanced imaging or nuclear medicine services in a physician office or outpatient facility setting.You have been asked to pay a $300 copayment for the hepatobiliary system imaging. The hepatobiliary system imaging falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. Hepatobiliary system imaging is considered nuclear medicine. 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 forthe hepatobiliary system imaging provided on August 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on May 2, 2019.You asked the Plan to waive the copayment for office visit. You say that you had your annual wellness visit and should not be charged 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 $20 copayment for in a physician's office. You have been asked to pay a $20 copayment for office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The medical record shows that you were seen for a follow-up for medication refills.This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the office visit provided on May 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forextraspinal chiropractic manipulations provided from August 27, 2019 to August 29, 2019.You asked the Plan to pay fornon-spinal chiropractic manipulations. You say that you are appealing with medical records.The Plan denied your request. The Plan says the denial of payment for these services is correct, because these services are not covered by Medicare or the Plan 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 services at issue are not manual manipulation of the spine.Therefore, we decided that the Plan does not have to pay forextraspinal chiropractic manipulations provided from August 27, 2019 to August 29, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on November 14, 2018 by out of network provider,"the provider". You asked the Plan to pay foroutpatient lab work. You say that this claim has been incorrectly denied.The Plan denied your request. The Plan says no prior authorization was obtained for the services in question.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 forthe medical services provided on November 14, 2018 by out of network provider, "the provider".
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 7, 2019 by out of network provider.You asked the Plan to pay for physician services. You say that you were unaware that the physician was out-of-network. You say that if you had known you would have requested authorization for the visit.The Plan denied your request. The Plan says no prior authorization was obtained for the services in question.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 7, 2019 by out of network provider.