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

We decided that the Plan does not have to pay for a chest x-ray (71045) provided on October 14, 2019.
You asked the Plan to pay for the chest x-ray. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the column I code was paid under a separate claim, therefore the Column II code on this claim is not payable.
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, we have confirmed that code the chest x-ray has a bundled relationship with code 32555 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for a chest x-ray (71045) provided on October 14, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe mammogram provided on October 28, 2019.You asked the Plan to waive the copayment forthe mammogram. You say that the claim was processed as diagnostic and generated a copayment.The Plan denied your request. The Plan says the claim was reprocessed to only apply the copayment.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 $10 copayment after the deductible is met for each basic imaging service.You have been asked to pay a $10 copayment for the mammogram. The mammogram falls within the "Outpatient diagnostic tests and therapeutic services and 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 copayment forthe mammogram provided on October 28, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on December 19, 2018 to September 24, 2019 to the enrollee by an out of network (OON) provider.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services were rendered by an out-of-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 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 December 19, 2018 to September 24, 2019 to the enrollee by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for various services provided to the enrollee from June 15, 2019 to August 13, 2019.
You asked the Plan to pay for the services. You say that most of the services were emergent and medically necessary. The Plan denied your request. The Plan says that the services were not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The plan has not provided adequate information to make a decision, and they have not substantiated their denial. It's not fully clear why the services were denied. It's also not fully clear what services have already been approved. The plan has not provided documentation showing that the enrollee termed on July 31, 2019. Therefore, we decided that the Plan has to pay for various services provided to the enrollee from June 15, 2019 to August 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora chiropractic office visit (99203), electrical stimulation (G0283), and the application of hot or cold packs (97010) provided on October 16, 2019.You asked the Plan to pay fora chiropractic office visit, electrical stimulation, and the application of hot or cold packs. You say that this was billed incorrectly.The Plan denied your request. The Plan says these services are not covered by Medicare or the Plan.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 thatthe service at issue is not manual manipulation of the spine.Therefore, we decided that the Plan does not have to pay fora chiropractic office visit (99203), electrical stimulation (G0283), and the application of hot or cold packs (97010) provided on October 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pay forchiropractic services provided to the enrollee from August 28, 2019 to September 10, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthis is not a covered benefit.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 service at issue is not manual manipulation of the spine. The plan has paid for CPT 98941, but the remaining denied codes cannot be paid for.Therefore, we decided that the Plandoes not haveto pay forchiropractic services provided to the enrollee from August 28, 2019 to September 10, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient pathology services provided on April 30, 2018 by an out of network (OON) provider.
You asked the Plan to pay for outpatient pathology services. You say that these services were medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained for these services. The Plan says that there are in-network providers available.
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 outpatient pathology services provided on April 30, 2018 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the SNF admission. You say that you feel that daily therapy would be helpful to increase your strength. The Plan denied your request. The Plan says you are currently at your functional baseline and there is no evidence that daily therapy is needed to maintain this functional level.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 the SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the hospital on 2/25 due to COPD exacerbation. He has been bedbound for several months and is very deconditioned. The enrollee most requires contact guard assistance to supervison for all care. He has no complex wound care needs, or IV medication requirements. There are no nursing or therapy needs that are skilled, and warranting a SNF level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the monitored anesthesia care (MAC) provided to the enrollee on September 3, 2019.
You asked the Plan to pay for the anesthesia care. The Plan denied your request. The Plan says this is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that the presence of an underlying condition alone may not be sufficient evidence that MAC is necessary. The medical condition must be significant enough to impact on the need to provide MAC such as the patient being on medication or being symptomatic, etc. The presence of a stable, treated condition, of itself, is not necessarily sufficient. 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 anesthesia care. Our reviewer says that the requested anesthesia care was not medically reasonable and necessary. Our physician reviewer found that the enrollee is a 66-year-old female with low back pain, lumbosacral radiculopathy, and anxiety. The enrollee underwent left transforaminal epidural steroid injections (TFESI) at L4/L5, L5/S1 under monitored anesthesia care (MAC). Per review of the medical record, this enrollee is ASA class 2 (P2 - mild systemic disease). This procedure does not normally require MAC. The enrollee is not a high-risk individual clinically based upon the ASA class. 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 anesthesia care have not been met. Therefore, we decided that the Plan does not have to pay for the monitored anesthesia care (MAC) provided to the enrollee on September 3, 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 July 15, 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.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the durable medical equipment have not been met. Specifically, medical records do not support a prior face-to-face examination with the ordering physician within 6 months of ordering the DME or an appropriate use of telehealth. The submitted consultation notes do not support that a physical examination was performed. The information submitted does not confirm that Medicare coverage criteria have been met. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on July 15, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of pump with oxygenator or heat exchanger (99190) provided on October 10, 2019.
You asked the Plan to pay for the assembly and operation of pump with oxygenator or heat exchanger. You say that this was a necessary service. The Plan denied your request. The Plan says payment of this service is included in the DRG payment.
The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that CMS designates to be "inpatient-only" services. These services have an OPPS status indicator of "C" in the OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule. The service at issue in this appeal was billed with CPT code 99190. This code is listed with a status indicator of
"C" on Addendum B of the 2019 OPPS/ASC final rule. This means the service has been designated as "inpatient only", and therefore must be billed as part of an inpatient admission. Therefore, we decided that the Plan does not have to pay for the assembly and operation of pump with oxygenator or heat exchanger (99190) provided on October 10, 2019.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to reduce the copayment for the office visit. We decided that the Plan does not have to waive the copayment for the office visit.
You asked the Plan to waive the copayment for the office visit. You say that you should not be charged this copayment amount. The Plan says that you have been charged the correct cost sharing amount.
We decided that the Plan has to reduce the copayment for the office visit.
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles, and coinsurance). The records show that the provider practices Internal Medicine.
The Plan says that you must pay a $50 copayment for the office visit. Based on the plan contract, however, you cannot be asked to pay more than a $5 copayment for the office visit. Therefore, we decided that the Plan has to reduce the copayment for the office visit from a $50 copayment to a $5 copayment.
We also decided that the Plan does not have to waive the copayment for the office visit.
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 $5 copayment for the office visit. Therefore, we decided that the Plan does not have to waive the copayment for the office visit.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay fora Chest x-ray (71045) provided on October 18, 2019.You asked the Plan to pay forthe x-ray. You say that the services were medically necessary.The Plan denied your request. The Plan says the claim is a duplicate.The Plan must follow Medicare rules. Medicare rules say that duplicate claims cannot be paid. We looked at the file and Medicare rules. There is no modifier to indicate that this claim is for a repeat service. A claim has already been submitted for the same service on the date of service at issue. Based on this information, we decided that Medicare rules for coverage of the x-ray have not been met.Therefore, we decided that the Plan does not have to pay fora Chest x-ray (71045) provided on October 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided on August 14, 2019 through September 18, 2019.
You asked the Plan to pay for the home health services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says services received from a provider who does not participate in Medicare are not covered.
The Plan must follow Medicare rules. Medicare rules say that to receive payment, a provider or supplier must be enrolled in the Medicare program. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the home health services have not been met. Specifically, the record indicates that this provider does not participate in Medicare. Therefore, we decided that the Plan does not have to pay for home health services provided on August 14, 2019 through September 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a pneumatic compression device (E0652).
You asked the Plan to pre-approve a pneumatic compression device. You say that the enrollee requires the device. The Plan denied your request. The Plan says the documentation did not support the 4-week trial using the basic pump that Medicare requires.
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).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that you are in such severe pain you cannot walk properly. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a laparoscopy (47562) provided on October 4, 2019.
You asked the Plan to pay for a laparoscopy. You say that this should be paid. The Plan denied your request. The Plan says this claim must first be processed by the enrollee's primary insurance.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has instructed you to submit this claim to the enrollee's primary insurance.. As the secondary insurer, the Plan cannot be held responsible for a laparoscopy until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for a laparoscopy (47562) provided on October 4, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the Orthovisc billed with two units of code J7324 for the injection provided on September 13, 2019.
You asked the Plan to pay for the two units of J7324. You say that these two units of J7324 are supported. The Plan denied your request. The Plan says the code J7324 is for each dose. Therefore, two units cannot be billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units provided for each procedure code. We find that two units of CPT code J7324 are not supported in the medical record. The medical record only supports one unit of CPT code J7324. This code is one unit per dose. Only one dose was given on this date of service. Based on this information, we decided that Medicare rules for coverage of the two units of J7324 have not been met. Therefore, we decided that the Plan does not have to pay for the Orthovisc billed with two units of code J7324 for the injection provided on September 13, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the x-ray provided on June 20, 2019.
You asked the Plan to waive the copayment for the x-ray. You say that you already paid a $15 copayment for
the office visit. You say you are being billed a $15 copayment six months after the visit. 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 $15
copayment for in-network x-rays.
You have been asked to pay a $15 copayment for the x-ray. The x-ray falls within the "Outpatient diagnostic
tests and therapeutic services and supplies" benefit category. The record shows you were billed for an x-ray.
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 x-ray provided on June 20, 2019.
Your complaint about your doctor billing you because she does not like you is not a valid appeal for medical
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not
permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the out of network (OON) nephrology services provided on October 18, 2019.
You asked the Plan to pay for the OON nephrology services. You say that you need to continue seeing this provider as you are in stage III kidney disease and the nearest network provider is almost 50 miles away. The Plan denied your request. The Plan says that these services were not pre-authorized and were provided out of network. These cannot be covered.
Medicare rules say that plans must make care accessible to enrollees. According to Medicare rules, care is considered accessible to an enrollee if contract providers are available within reasonable distance and travel time from the enrollee's home. The plan contract says that enrollees must use contract providers. We were able to confirm that the Plan did not have contract providers located within reasonable distance and travel time from your home who could have provided these services. A search of the plan's website did not reveal any providers closer than 45 miles away. Under Medicare rules, this means that contract providers were not accessible to you. Therefore, we decided that the Plan has to pay for the out of network (OON) nephrology services provided on October 18, 2019.