Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on February 3, 2020 by an out of network (OON) provider.You asked the Plan to pay for office visit. You say that this was related to a visit with an in-network doctor.The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and the referring physician was also out-of-network with 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 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 February 3, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for surgical procedure provided on March 13, 2020.
You asked the Plan to waive the coinsurance for the surgical procedure. You say that you were told this outpatient ambulatory surgery would be covered in full when you initially applied for coverage with the plan. The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 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 had a surgical procedure performed on March 13, 2020. You are asked to pay 20% coinsurance for the surgery. Your EOC states, enrollees must pay 20% coinsurance per visit for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. 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 coinsurance for surgical procedure provided on March 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652 and E0667).
You asked the Plan to pre-approve a pneumatic compression device. You say that you would like
reconsideration because this device is medically necessary. The Plan denied your request. The Plan says
Medicare requires an appropriate good faith attempt with the basic pump (E0650 or E0651) per the guidelines
for four weeks.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily,
multiple-hour home usage of the E0650 or E0651 is required.
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, the record does not show that the enrollee had at least
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting,
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device
(E0652 and E0667).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided on February 5,
2020.
You asked the Plan to waive the copayment for an office visit. You say that this was an annual wellness visit
and 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 $15
copayment for each primary care visit.
The medical records show that you received services beyond an annual wellness visit on February 5, 2020.
Therefore, you are responsible to pay the $15 copayment.
You have been asked to pay a $15 copayment for an office visit. An office visit falls within the
physician/practitioner services, including doctor's office visits 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 an office visit provided on February 5, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the speech/hearing therapy services provided on November 1, 2019 to November 12, 2019 by an out of network (OON) provider.You asked the Plan to pay for the speech/hearing 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.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 speech/hearing therapy services provided on November 1, 2019 to November 12, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the injections and chemotherapy
administration provided on January 8, 2020 and January 22, 2020.
You asked the Plan to waive the cost share for the injections and chemotherapy administration. You say that
you have never been charged twice for an injection. You say that the coinsurance is higher than normal. The
Plan denied your request. The Plan says the cost share 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 20%
coinsurance for each Medicare-covered Part B drug from an in-network provider and a $15 copayment per visit
for an in-network primary care physician or specialist.
You have been asked to pay a total of $1,175 for the injections and chemotherapy administration.
Date of Service Service Allowed Amount Standard Cost Member Liability
January 8, 2020 Bevacizumab Injection $4,284.36 20% $287.65
January 8, 2020 Ondansetron Hydrochloride
Injection
$2.42 20% $0.48
January 8, 2020 Chemotherapy
Administration
$136.19 $15 $15
January 22, 2020 Bevacizumab Injection $4,284.36 20% $856.87
January 22, 2020 Chemotherapy
Administration
$136.19 $15 $15
TOTAL: $1,175
The injections fall within the "Medicare Part B prescription drugs" benefit category. The chemotherapy
administration falls within the "Physician/Practitioner services, including doctor's office visits" 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 cost share for the injections and chemotherapy administration
provided on January 8, 2020 and January 22, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 84270, 83090, 84378, 86021, 84681, and 82746 provided on June 18, 2019. You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the documentation does not support the services billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.s We find that CPT codes 84270, 83090, 84378, 86021, 84681, and 82746 are 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. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 84270, 83090, 84378, 86021, 84681, and 82746 provided on June 18, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 93010) provided on September 29, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the documentation
received does not support for CPT 93010.
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 93010 is "Electrocardiogram, routine ECG with at least
12 leads; interpretation and report only".
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 use
of CPT code 93010 is not supported by the records provided. Our physician reviewer found that the medical
records submitted do not include a complete, written report similar to that which would be prepared by a
specialist in the field, therefore this service is not separately reimbursable. Payment is bundled in the
emergency room visit (CPT 99285), which was also performed on the same date of service, by the same
physician in the same group/practice.
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 the services (CPT 93010) provided on September 29, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Dynasplintsystem for the enrollee.You asked the Plan to pre-approvethese services. You say that this is medically necessary for the enrollee.The Plan denied your request. The Plan says that it has not been demonstrated that the Dynasplint device improves outcomes of shoulder pathology when compared to conventional treatment.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 pre-approve these services. Our reviewer says that the Dynasplint system is not considered medically reasonable and necessary in this case. The requested Dynasplint system (Dynamic adjustable shoulder flexion/abduction/rotation device, includes soft interface material; E1840) has a lack of scientific evidence regarding its effectiveness for the patient's shoulder condition due to her intracerebral hemorrhage. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of this item.We looked at this physician's review, the file, and Medicare rules. 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 pre-approvea Dynasplint system for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the electromyography billed for services provided on November 21, 2019.
You asked the Plan to pay for the service at issue. You say that the report shows the needle EMG was performed. 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. In this case, the CPT Code Manual definition of code 95868 is needle electromyography; cranial nerve supplied muscles, bilateral. We find that CPT code 95868 is not supported in the medical record. Specifically, the records do not show that a needle electromyography for bilateral cranial nerves was performed. 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 electromyography billed for services provided on November 21, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services (97110, 97530, 97024) provided from January 1, 2019 to January 31, 2019.You asked the Plan to pay for physical therapy services. You say that the filing of this claim was denied due to billing management turnover.The Plan denied your request. The Plan says claims must be filed within a year of the date of service.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service.The record shows that a claim for physical therapy services was not filed until February 24, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay for physical therapy services (97110, 97530, 97024) provided from January 1, 2019 to January 31, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids (V5298) and sales sat (S9999) purchased January 29, 2020.
You asked the Plan to pay for the hearing aids and sales tax.. You say that you purchased the first sent 2 1/2 years ago and was reimbursed. A plan representative told you it was ok to go to this provider so you are confused as to why this was denied. The Plan denied your request. The Plan says hearing aids orders through other providers other than the preferred vendor are not covered. Sales tax is not a covered benefit.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when purchased from the preferred vendor. Sales tax is not a covered benefit. We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aids and sales tax. have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids (V5298) and sales sat (S9999) purchased January 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 23, 2019 to December 18, 2019 by an out of network (OON) provider.You asked the Plan to pay for psychotherapy visit. You say that you were told that care with this provider had been approved.The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and a referral was not obtained.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 October 23, 2019 to December 18, 2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on December 26, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. The Plan denied your request. The Plan says the enrollee's plan requires utilization of network providers, and authorization for certain services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The documentation shows a duplex scan of the extremity veins was provided to the enrollee. The requested 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 services at issue. We found no exception that would require the Plan to pay for these OON services. Therefore, we decided that the Plan does not have to pay for the medical services provided on December 26, 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 the train of four testing provided on July 17, 2019.
You asked the Plan to pay for train of four testing. The Plan denied your request. The Plan says there is no separate CPT code for train of four monitoring.
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 95937 is neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method. We find that CPT code 95937 is not supported in the medical record. Train of Four Testing does not fit the criteria set by CMS and Insurance Carriers for CPT 95937. There is no separate code for Train of Four Monitoring, therefore, it would be inappropriate to bill the Neuromuscular Junction Testing code for Train of Four Monitoring. 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 train of four testing provided on July 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lumbar sacral orthosis provided to the enrollee onJanuary 30, 2020.You asked the Plan to pay forthe orthosis. You say that this was medically necessary.The Plan denied your request. The Plan says that the reasonable useful lifetime of equipment but in no case can it be less than 5 years.The Plan must follow Medicare rules. Medicare rules say that the reasonable useful lifetime of equipment in no case can be less than five years. The enrollee received a lumbar sacral orthosis on February 14, 2019, which is less than five years ago.Therefore, we decided that the Plan does not have to pay forthe lumbar sacral orthosis provided to the enrollee on January 30, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that you feel that you need intensive therapy to prevent
another fall and further injury. The Plan denied your request. The Plan says the criteria for this level of care are
not met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
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 pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the enrollee presented to the ED on 5/26/2020 with vomiting and generalized illness.
She was also found to have a dislocated hip prosthesis. She had an IR aspiration of to evaluate for infection. It
was not felt that she had a septic arthritis. On 5/31/20 she had a closed reduction of left prosthetic hip
dislocation, requiring anesthesia. She then had a closed reduction and examination of THR with fluoroscopy
after a repeat dislocation on 6/3/2020. She was to wear a brace when out of bed and it was to avoid flexion
beyond 70 degrees.
The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital
inpatient stay with an interdisciplinary approach to rehabilitation care. The patient's current medical status does
not require intensive physician or nursing oversight in an IRF. The patient may benefit from additional
therapies, however the patient's functional level which is does not require or indicate that this therapy must be
in an IRF with an intensive level program.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.