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

We decided that the Plan does not have to pay for an intermittent limb compression device (E0651) provided to the enrollee April 26, 2019.
You asked the Plan to pay for the intermittent limb compression device. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation submitted did not include an itemized shipping/billing invoice to corroborate with the proof of delivery.
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 physician order and 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 documentation submitted did not include an itemized shipping/billing invoice to corroborate with the proof of delivery. Therefore, we decided that the Plan does not have to pay for an intermittent limb compression device (E0651) provided to the enrollee April 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397)
provided to the enrollee on February 20, 2019.
You asked the Plan to pay for the orthoses. 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 for a knee orthosis with
suspension sleeve (L1833, L2397) provided to the enrollee on February 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit provided a participating provider on January 25, 2020.
You asked the Plan to waive the copayment for a specialist office visit. You say that you went for a primary office visit. You say that if you wanted to see a specialist you would have asked for that. The Plan denied your request. The Plan says the correct copayment has been applied.
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 $35 copayment for physician/practitioner services/specialist visit. You have been asked to pay a $35 copayment for a specialist office visit. Since services were provided by a specialist, the correct copayment has been applied. A specialist office visit falls within the physician/practitioner services/specialist visit 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 a specialist office visit provided by a participating provider on January 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an outpatient clinic visit provided on January 24, 2019.
You asked the Plan to pay for the outpatient clinic visit. The Plan denied your request. The Plan says nonemergent,
non-urgent services with out-of-network providers require 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 Plan did not pre-approve the
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we
decided that the Plan does not have to pay for an outpatient clinic visit provided on January 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on October 4, 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 for a lumbar-sacral orthosis (L0650) provided to the enrollee on October 4, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two precision attachments and a partial overdenture.
You asked the Plan to pre-approve the precision attachments and partial overdenture. You say that the Plan's ad said that the optional benefit would cover dentures. You also say that the Plan's ad did not specify what kind of dentures would be covered. The Plan denied your request. The Plan says these services are not covered under your plan.
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 services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve two precision attachments and a partial overdenture.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulatory surgery services provided on December 18,
2019.
You asked the Plan to pay for the ambulatory surgery services. The Plan denied your request. The Plan says
non-emergent, non-urgent services with out-of-network providers require 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 Plan did not pre-approve the
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we
decided that the Plan does not have to pay for ambulatory surgery services provided on December 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the compression stockings identified with code A6530 that were issued on February 25, 2020.
You asked the Plan to pay for the compression stockings. You say that you were told that the stockings would be covered. The Plan denied your request. The Plan says the stockings are noncovered per Medicare rules.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression stockings identified with code A6530 that were issued on February 25, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on January 29, 2020.
You asked the Plan to waive the copayment for the emergency room visit. You say that you should not have to pay the copayment given the lack of treatment. 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 $90 copayment for emergency care. You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls within the "Emergency care" benefit category. The medical record shows you were evaluated and received services during your emergency room visit.
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 emergency room visit provided on January 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient services provided on November 22, 2019.
You asked the Plan to pay for the outpatient services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for outpatient services provided on November 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 99053, CPT 36000) provided on
November 3, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are
bundled.
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "B" under the Physician Fee
Schedule indicates that payment for covered services are always bundled into payment for other services not
specified.
We looked at the file and Medicare rules. Procedure codes 99051 and 36000 are assigned a status indicator of
"B" under the Physician Fee Schedule, which means that these are bundled services. Payment for these services
is bundled into payment for other services. No separate payment can be made for these services. 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 99053, CPT 36000) provided on November 3,
2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the arthrocentesis and methylprednisolone
acetate injection provided on January 14, 2020.
You asked the Plan to waive the copayment for the arthrocentesis and methylprednisolone acetate injection.
You say that you have never had to pay for the injections before. You say that you don't feel responsible. The
Plan denied your request. The Plan says the copayment applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30
copayment for in-network specialist visits. Covered services include medically necessary medical care or
surgery services furnished in a physician's office. Your contract with the Plan clearly says that you must pay a
$50 copayment for Part B drugs that are administered by an in-network provider.
You have been asked to pay a total of $50 for the arthrocentesis and methylprednisolone acetate injection.
The arthrocentesis falls within the "Physician/Practitioner services, including doctor's office visits" benefit
category. The methylprednisolone acetate injection falls within the "Medicare Part B prescription drugs"
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 arthrocentesis and
methylprednisolone acetate injection provided on January 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for DME and related supplies provided on
November 1, 2019.
You asked the Plan to waive the coinsurance for DME and related supplies. You say that you disagree with the
charges because you were told you would not owe anything. 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 20%
coinsurance for DME and related supplies.
You received DME and related supplies on November 1, 2019. The total allowed amount is $1,228.82 and 20%
of that is $245.77.
You have been asked to pay the total coinsurance amount of $245.77 for DME and related supplies. DME and
related supplies fall within the DME and related supplies benefit category. This means that you have been
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have
to waive the coinsurance for DME and related supplies provided on November 1, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the inpatient stay provided from January 3, 2020 through January 7, 2020.
You asked the Plan to waive the cost share for the inpatient stay. You say that you believe the enrollee is being overcharged $300. You say that there should only be one charge. 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. The enrollee's contract with the Plan says that the deductible is $750. This is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. Until you have paid the deductible amount, you must pay the full cost of your covered services. The enrollee's contract with the Plan also says that enrollees must pay a $300 copayment per admission after the deductible is met for each medically necessary inpatient stay. The item or service you asked the Plan to waive the cost share for falls within the "Inpatient hospital care" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that the $750 deductible applies to inpatient hospital care. This cost sharing is a contractual obligation that had not been met at the time the inpatient stay was received from January 3, 2020 through January 7, 2020. Therefore, $375.23 has been applied to meet the deductible.
Since the deductible was met, the enrollee has also been asked to pay a $300 copayment. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay when enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the cost share for the inpatient stay provided from January 3, 2020 through January 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on November 22, 2019.
You asked the Plan to pay for the orthoses. 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. The rules state that DMEPOS is covered only when the patient's medical record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use. The record shows that documentation submitted did not indicate the provider discussed the need for the billed supply code, so the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on November 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the tetanus, diphtheria, and acellular pertussis (TDaP) vaccine rendered on December 31, 2019.
You asked the Plan to pay for these services. You say that the physician said you needed the vaccine. The Plan denied your request. The Plan says the services are not covered.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide these services. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to these services. Therefore, we decided that the Plan does not have to pay for the tetanus, diphtheria, and acellular pertussis (TDaP) vaccine rendered on December 31, 2019.
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on December 16, 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. The rules state that DMEPOS is covered only when the patient's medical record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use. The record shows that documentation submitted did not indicate the provider discussed the need for the billed supply code, so the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on December 16, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthoses and sleeves provided to the enrollee on November 29, 2019.
You asked the Plan to pay for the orthoses and sleeves. The Plan denied your request. The Plan says that the billed services were not supported.
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 the knee orthoses and sleeves provided to the enrollee on November 29, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair expandable controller with harness
and connector (E2311, E2377, E2313).
You asked the Plan to pre-approve the controller and accessories. You say that the expandable controller is
medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that expandable controllers can only be covered when
medically necessary.
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 the controller and accessories. Our
reviewer says that the requested expandable controller and accessories is not medically necessary. Our
physician reviewer found the documentation does not indicate that the patient requires a proportional input
device (e.g., mini, compact, or short throw joysticks, touchpads, chin control, head control, etc.) other than a
standard proportional joystick.
The documentation indicates the patient has sufficient strength to control the power features through their own
individual switches.
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 controller and accessories have not been met. Therefore, we decided that the
Plan does not have to pre-approve a power wheelchair expandable controller with harness and connector
(E2311, E2377, E2313).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (CPT 74018) provided to the enrollee on
December 30, 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 the denied code - CPT 74018 - is a column II procedure to the column I procedure - CPT 74019.
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 74018 is "Radiologic examination, abdomen."
We find that CPT code 74018 is not supported in the medical record. Specifically, this code is a column II
procedure to the column I procedure already billed on this claim - CPT 74019. This denied code cannot be
billed separately. 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 radiology services (CPT 74018)
provided to the enrollee on December 30, 2019.