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

We decided that the Plan does not have to pay for the services rendered to the enrollee.  We decided that the Plan does not have to pay for the services rendered to the enrollee by the Provider on August 23, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the enrollee was on hospice.
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 the services rendered to the enrollee by by the Provider on August 23, 2019.r on August 23, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the enrollee was on hospice.
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 the services rendered to We decided that the Plan does not have to pay for the services rendered to the enrollee by the provider on August 23, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the enrollee was on hospice.
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 the services rendered to the enrollee by the Provider on August 23, 2019. on August 23, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab work received on June 3, 2019.You asked the Plan to waive the copayment for the services. You say that this is usually covered at 100%.The Plan denied your request. The Plan says the copayment was 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 (suchas copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $7 copayment for lab services. You have been asked to pay a $7 copayment for the services. The services fall within the lab 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 copayment for lab work received on June 3, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forparamedic intercept provided on. June 2, 2019You asked the Plan to pay forthe paramedic intercept. You say that paramedic intercepts are a covered and reimbursable procedure and you request this claim be sent for adjustment and payment.The Plan denied your request. The Plan says resubmit with other CPT/HCPCS code.The rules say that Medicare pays for advanced life support (ALS) paramedic intercept services only when the services are furnished in a rural area. The paramedic intercept services at issue in this appeal were not furnished in a rural area.Therefore, we decided that the Plan does not have to pay forparamedic intercept provided on June 2, 2019
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on August 15, 2019 by out of network provider, "the provider" You asked the Plan to pay foroutpatient lab work. You say that it should be the providers job to get prior authorization. You say that the lab should not be penalized for the lack of prior authorization.The Plan denied your request. The Plan says no prior authorization was applied. The Plan says that the referring doctor."the 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 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 requirethe Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe medical services provided on August 15, 2019 by out of network provider, "the provider".
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe prophylaxis, periodic oral evaluation, bitewings, and intraoral radiographic imaging services provided on August 28, 2019.You asked the Plan to pay forthese dental services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services received are not a covered benefit.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or servicesare not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe prophylaxis, periodic oral evaluation, bitewings, and intraoral radiographic imaging services provided on August 28, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on July 9, 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 there is evidence of misrepresented 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.We find that CPT code 81270 and HCPCS G0452 are not supported in the medical record. Specifically, the Delivery Ticket submitted did not include the carrier's tracking number, nor did the Proof of Delivery include an order number or details to corroborate the Delivery Ticket submitted.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 July 9, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the provision of INR test materials rendered to the enrollee by the provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was not billed correctly.
The Plan must follow Medicare rules. The rules say that one unit of code G0249 is for four tests and that claims may be submitted no more than 25 days from the previous claim. The file shows that the provider submitted a claim for procedure code G0249 that was paid by the plan. The same procedure code was submitted for less than 25 billing days from the previously approved claim. Therefore, we decided that the Plan does not have to pay for the provision of INR test materials rendered to the enrollee by the provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy services coded S9328 provided.
You asked the Plan to pay for the home infusion therapy services. 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 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 S9328 is Home infusion therapy, implanted pump pain management infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem. We find that CPT code S9328 is not supported in the medical record. Specifically, code S9328 has a status code of "I". A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy services coded S9328 provided.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered to the enrollee.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 for the drug testing rendered to the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on March 15, 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 March 15, 2019 by the out
of network provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the prothrombin time services provided on May 3, 2019.You asked the Plan to pay for the prothrombin time services. You say that you would like the plan to reconsider their decision.The Plan denied your request. The Plan says the enrollee was enrolled in hospice for this date of service.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 the prothrombin time services provided on May 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on June 26, 2019 to July 31, 2019 by the out of network provider.You asked the Plan to pay for these services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services were rendered by a non-network provider without prior authorization.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The referring provider is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe medical services provided on June 26, 2019 to July 31, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for test strips, lancets, control solution, and batteries provided from July 27, 2019 to October 15, 2019.You asked the Plan to pay for test strips (A4253), lancets (A4259), control solution (A4256), and batteries (A4235). You say that the Plan should pay this claim.The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered.Therefore, we decided that the Plan does not have to pay for test strips, lancets, control solution, and batteries provided from July 27, 2019 to October 15, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided by on June 25, 2019.You asked the Plan to pay for the ambulance services. You say that the Plan should pay this claim.The Plan denied your request. The Plan says Original Medicare is responsible for this claim.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 beneficiary 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 the ambulance services provided on June 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the diabetic supplies rendered to on June 19, 2019 to September 7, 2019.You asked the Plan to pay for these services. You say that you disagree with the denial.The Plan denied your request. The Plan says there is no valid proof of delivery.The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS suppliers are required to maintain proof of delivery.We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. 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 diabetic supplies rendered on June 19, 2019 to September 7, 2019.
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.
You asked the Plan to pay for home health services. You say that these services should be covered. The Plan denied your request. The Plan says these services were not billed with an appropriate Q code on the claim.
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 claim did not include an appropriate CPT code to report the location in which the services were rendered. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora colonoscopy provided by "the provider" on August 1, 2019.You asked the Plan to waive the copayment fora colonoscopy. You say that you disagree with the charges.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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $260 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. The medical records show that you had polyps removed during a colonoscopy on August 1, 2019. Therefore, the colonoscopy is considered diagnostic, not preventative, and you are responsible to pay the $260 copayment. You have been asked to pay a $260 copayment for a colonoscopy. A colonoscopy falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 fora colonoscopy provided by "the provider" on August 1, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services provided from May 8, 2019 to June 18, 2019.You asked the Plan to pay for the physical therapy services. The Plan denied your request. The Plan says the billed services cannot be verified.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.The file shows that gait training (97116) was billed for services provided on May 8, 10, 13, 16, 21, 23, and 30, 2019; June 4, 5, 1, 13, and 18, 2019. Therapeutic exercises (97110) were billed for services provided on May 8, 10, 13, 16, and 21, 2019; June 5 and 11, 2019. Neuromuscular re-education was billed for services provided on June 11, 13, and 18, 2019. Electrical stimulation was billed for services provided on June 11, 2019. We find that the CPT codes at issue are not supported in the medical record. The records show that multiple attempts were made by the plan to obtain additional information. However, none were provided. Based on this information, we decided that Medicare rules for coverage have not been met.Therefore, we decided that the Plan does not have to pay for the physical therapy services provided from May 8, 2019 to June 18, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing provided on July 22, 2019.You asked the Plan to pay for the drug testing. The Plan denied your request. The Plan says the documentation does not itemize what tests are included in the panel.The Plan follows Medicare rules. Medicare rules say that definitive UDT orders should be individualized based on clinical history and risk assessment, and must be documented in the medical record.The file shows that the enrollee received definitive drug testing of 15-21 drug classes. 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 drug testing. Our physician reviewer found that the records do not include a provider order indicating the specific tests to be performed. Without this, coverage criteria were not met. Therefore, medical necessity cannot be determined. 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 drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the definitive drug testing provided on July 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on May 17, 2019 by out of network provider, "the surgical center".You asked the Plan to pay foroutpatient services. You say that the member gave you incorrect information. You say that you were not aware that you were out-of-network.The Plan denied your request. The Plan says there was no prior authorization obtained. The Plan says that the referring doctor, "the doctor", is also 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 forthe medical services provided on May 17, 2019 by out of network provider, "the surgical center".
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe definitive drug testing provided the "beneficiary" on July 9, 2019.You asked the Plan to pay forthe drug testing. The Plan denied your request. The Plan says the billed date of service is not within the 1 year effective date of the toxicology profile.The Plan must follow Medicare rules. Medicare rules say that definitive drug testing is only covered under certain medical indications. We find that CPT code G0483 is not supported in the medical record. The medical records provided shows that the enrollee was compliant behavior with signed pain management contract. There is no evidence that shows the testwas individualized to identify 22or more specific non-prescribed medications or illicit substances. The records provided do not document concerns based on clinical review and judgement.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 definitive drug testing provided to the "beneficiary" on July 9, 2019.