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

We decided that the Plan does not have to pay for the ankle foot orthoses, and addition to lower extremities provided on November 25, 2019.
You asked the Plan to pay for the ankle foot orthoses (L1940), and additions to lower extremity (L2330, L2820). You say that the orthoses were medically necessary. The Plan denied your request. The Plan says the billed services are not supported.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file, and Medicare rules. There is no documentation of exam, x-rays, or plan of care, supporting the orthoses. There is no proof of delivery. Based on this information, we decided that Medicare rules for coverage of the ankle foot orthoses (L1940), and additions to lower extremity (L2330, L2820) have not been met. Therefore, we decided that the Plan does not have to pay for the ankle foot orthoses, and addition to lower extremities provided on November 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye exam provided on March 2, 2020.
You asked the Plan to waive the copayment for the eye exam. You say that the visit was for a routine checkup.
You say that you aren't paying anything. 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 $35
copayment for Medicare-covered eye exams to diagnose and treat diseases and conditions of the eyes.
You have been asked to pay a $35 copayment for the eye exam. The eye exam falls within the "Vision care"
benefit category. The records show that a medical eye exam was performed. 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 eye exam provided on March 2, 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 the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 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 records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other medication management, wound/skin care, and daily therapy can be provided at a SNF. In this case, the enrollee is mostly minimal assist for functional transfers and activities of daily living (ADL's) and a less intensive, longer duration of therapy will allow for measurable gains to be attained within a predicted period.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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on February 19, 2020.You asked the Plan to waive the copayment for a specialist visit. You say that this was a follow-up 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 $35 copayment for each specialist visit. You had a specialist visit on February 19, 2020. Follow-up visits are subject to cost-sharing charges. Therefore, you are responsible to pay the $35 copayment. You have been asked to pay a $35 copayment for a specialist visit. A specialist 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 a specialist visit provided on February 19, 2020.
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 from September 11, 2019 to October 21, 2019.You asked the Plan to pay for home health services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services were billed incorrectly.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, a request for anticipated payment (RAP) is required in order to process home health claims.A RAP was not provided on the claims submitted. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from September 11, 2019 to October 21, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for fabrication and fitting (V2628) prosthetic custom plastic eye (V2623) reduction of eye prosthesis (V2626) polishing artificial eye (V2624) provided October 9, 2019.
You asked the Plan to pay for the prosthesis. You say that the records should support the necessity of the service in dispute. The Plan denied your request. The Plan says the documentation does not support the services billed.
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 a signed delivery sheet for the items at issue in this appeal. The record does not contain a valid physician order and a signed delivery sheet for the supplies provided in this case. Therefore, we decided that the Plan does not have to pay for fabrication and fitting (V2628) prosthetic custom plastic eye (V2623) reduction of eye prosthesis (V2626) polishing artificial eye (V2624) provided October 9, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on February 6, 2020.
You asked the Plan to pay for the drug testing 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 the physician must clearly document, in the
medical record, his or her intent that the test be performed.
We looked at the file and Medicare rules. The records provided do not contain documentation of the ordering
physician's intent that the tests be performed. Based on this information, we decided that Medicare rules for
coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to
pay for the drug testing services provided on February 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services provided on January 2, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the chiropractic services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.
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 chiropractic services provided on January 2, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy (S9328) provided July 17, 2019 to October 15, 2019.
You asked the Plan to pay for HCPCS code S9328. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the claim was submitted with a code that is not payable by Medicare.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate HCPCS/CPT code. The rules also say that HCPCS/CPT codes with a status indicator of I are not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, these services. We find that payment for CPT code S9328 is not supported. Specifically, CPT code S9328 has a status code indicator of I and will not be paid by Medicare. This service should be reported with a code that is recognized by Medicare. Based on this information, we decided that Medicare rules for coverage of CPT code S9328 have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy (S9328) provided July 17, 2019 to October 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on January 6, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are available in-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 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 services. Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on January 6, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an x-ray provided by an outpatient hospital facility on February 3, 2020.You asked the Plan to waive the copayment for an x-ray. You say that this was done at an urgent center. You say that your copayment should be $20. 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 $75 copayment for outpatient diagnostic tests/basic radiology services/outpatient hospital. You have been asked to pay a $75 copayment for an x-ray. The facility that was used is considered an outpatient hospital facility; therefore, the correct copayment has been applied. An x-ray falls within the outpatient diagnostic tests/basic radiology services/outpatient hospital 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 x-ray provided by an outpatient hospital facility on February 3, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport and ER visit provided on January 13, 2020.You asked the Plan to waive the copayment for the ambulance transport and ER visit. You say that her blood pressure should have been taken. You say that she shouldn't be responsible for the ambulance ride or ER visit.The Plan denied your request. The Plan says the copayments 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $260 copayment for Medicare-covered ambulance transport (one-way) and a $90 copayment for each Medicare-covered emergency room visit in-network and out-of-network.The enrollee has been asked to pay a $260 copayment for the ambulance transport and a $90 copayment for the ER visit. The ambulance transport falls within the "Ambulance services" benefit category. The ER visit falls within the "Emergency care" benefit category. The records show that the enrollee was transported by ambulance to the hospital and treated in the ER. 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 upon enrolling in the Plan.Therefore, we decided that the Plan does not have to waive the copayment for the ambulance transport and ER visit provided on January 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for durable medical equipment provided by a participating provider on October 28, 2019.You asked the Plan to waive the coinsurance for durable medical equipment. You say that you have never been charged for this before. You say that this durable medical equipment was necessary for the surgery. The Plan denied your request. The Plan says the correct coinsurance 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 20% coinsurance for durable medical equipment. You have been asked to pay a 20% coinsurance of the allowed amount for durable medical equipment. The total allowed amount is $1,900.38. The total amount you are being asked to pay is $380.07 ($1,900.38 x 20% = $380.7). The correct coinsurance has been applied to the equipment that was provided. Durable medical equipment falls within the durable medical equipment 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 durable medical equipment provided by a participating provider on October 28, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the repair of central venous access devices provided on November 1, 2019 and November 26, 2019.You asked the Plan to waive the copayments for the repair of central venous access devices. 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 $300 copayment for surgery services provided in an outpatient hospital facility.You received the repair of central venous access devices on November 1, 2019 and November 26, 2019. Therefore, you are responsible to pay a $300 copayment per each surgery service. The total amount you owe is: $600.  You have been asked to pay the total copayment amount of $600 for the repair of central venous access devices. The repair of central venous access devices 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 copayments for the repair of central venous access devices provided on November 1, 2019 and November 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the EKG and echocardiography provided on November 26, 2019 and December 5, 2019.
You asked the Plan to waive the copayment for the EKG and echocardiography. You say that you were erroneously billed for a routine exam. You say that you should be reimbursed. The Plan denied your request. The Plan says the copayments 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 $20 copayment for Medicare-covered non-radiological diagnostic services and a $100 copayment for each Medicare-covered radiological diagnostic service. You have been asked to pay a $20 copayment for the EKG and a $100 copayment for the echocardiography. The EKG and echocardiography fall within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. The records show that you are only responsible for the diagnostic test copayments. 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 EKG and echocardiography provided on November 26, 2019 and December 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for psychiatric services provided on January 28, 2020 by an out of network (OON) provider.
You asked the Plan to pay for psychiatric services. You say that you were told you have to do a year of follow-up by the medical staff. You say that this was court ordered. The Plan denied your request. The Plan says no prior authorization was 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 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 psychiatric services provided on January 28, 2020 by an out of network (OON) provider
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Veltassa 16.8 GM Powder Packet.You asked the Plan to pre-approve Veltassa 16.8 GM Powder Packet. You say that the requested medication is necessary.The Plan denied your request. The Plan says the enrollee has a medical only policy which does not include Part D prescription coverage, therefore the criteria for self-administered drug coverage has not been met.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approve Veltassa 16.8 GM Powder Packet.Benefits for Veltassa 16.8 GM Powder Packet 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the vitamin D testing provided on February 11, 2020.You asked the Plan to pay for the vitamin D testing. The Plan denied your request. The Plan says this is not covered as a screening test.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.The vitamin D testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes.Therefore, we decided that the Plan does not have to pay for the vitamin D testing provided on February 11,2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for injection services provided to the enrollee on July 30, 2018.
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 codes remain not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate code.
In this case, the CPT Code Manual definition of the denied codes is:
HCPCS J2001:
injection, lidocaine HCl for intravenous infusion
HCPCS A4670:
Automatic bp monitor, dial
We asked our coding reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the
services at issue in this case were not coded correctly. Our coding reviewer found the medical records provided
do not include documentation to support 2 units of Injection, lidocaine HCl for intravenous infusion, 10 mg
being performed on July 30, 2018, therefore this service cannot be verified. HCPCS code A4670 is considered
a non-covered service by Medicare, therefore this service is not eligible for separate reimbursement.
We looked at this coder'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 injection services provided to the enrollee on July 30, 2018.