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

We decided that the Plan does not have to pay for the supply allowance for therapeutic continuous glucose monitor (cgm) provided on February 13, 2021.
You asked the Plan to pay for the supply allowance for therapeutic continuous glucose monitor (cgm). You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the documentation did not document the need for the items rendered.
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 does not contain relevant medical records which support medical necessity for the supplies provided in this case. Review of the file shows that the documentation submitted did not sufficiently document the enrollee's medical condition to support the necessity for the billed supply code. In addition, the documentation did not indicate that the provider discussed the need for the billed supply code. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the supply allowance for therapeutic continuous glucose monitor (cgm) provided on February 13, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport provided on March 30, 2021.
You asked the Plan to pay for ambulance service, basic life support, non-emergency transport. You say that transportation by ambulance was required due to severe muscle weakness, non-ambulatory, high fall risk, altered mental status and morbid obesity. You say that transportation by any other means would endanger the well-being of the patient. The Plan denied your request. The Plan says the enrollee could have been safely transported by another type of motor vehicle, possibly a van transport vehicle.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 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 ambulance service, basic life support, non-emergency transport. Our reviewer says that the ambulance transport was not medically necessary. Our physician reviewer found that the Medicare rules say that ambulance services are only covered when the enrollee's clinical condition is such that other methods of transport are contraindicated. In this case, the record indicates that the enrollee was transported to a mental health appointment on a stretcher. The record does not indicate that other methods of transport are medically contraindicated. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ambulance service, basic life support, non-emergency transport have not been met. Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport provided on March 30, 2021
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on November 24, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that CMS does not pay for an "inpatient-only" service
furnished to a person who is registered in the hospital as an outpatient.
We looked at the file and Medicare rules. Billed procedure code 61750 (stereotactic biopsy, aspiration, or
excision, including burr hole(s), for intracranial lesion) is on the inpatient only list. The file shows that the code
was billed on an outpatient claim and is therefore not payable. Therefore, we decided that the Plan does not
have to pay for the surgical services rendered on November 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (J1030) provided on October 20, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not supported.

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 J1030 is "Injection, methylprednisolone acetate, 40 mg."

We asked our coder 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 code J1030 is not supported by the records provided. Our reviewer found that the documentation does not specify medication or dosage given to confirm code J1030.

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 the services (J1030) provided on October 20, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on February 11, 2021.
You asked the Plan to pay for lab tests. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because predictive screening testing is not a Medicare benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The testing at issue in this appeal, lab tests, were requested for screening purposes. Medicare does not cover these tests for screening purposes. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on February 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuromuscular stimulator and supplies provided to the enrollee on January 7, 2021.

You asked the Plan to pay for these items. You say that this should be covered. The Plan denied your request. The Plan says the billed supply code cannot be verified.

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 does not contain a valid proof of delivery for the supplies provided in this case. The Packing Slip submitted did not include the carrier's tracking number, nor did the Proof of Delivery include an order number or details to corroborate the Delivery Ticket submitted. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the neuromuscular stimulator and supplies provided to the enrollee on January 7, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided February 22, 2021.
You asked the Plan to pay for the ambulance services. You say that you are requesting payment of the ambulance services. The EMS arrived and was able to stabilize your blood sugar, so you decided not to be transported. The Plan denied your request. The Plan says this service is not covered.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on February 22, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided February 22, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care beyond June 30, 2021.
You asked the Plan to pre-approve the continued SNF care. You say that the enrollee would benefit from continued care in the SNF. The Plan denied your request. The Plan says there are no longer any daily skilled service needs.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 continued SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the beneficiary is an 80 year old male with sepsis, dementia, and Parkinson's disease. From a nursing perspective, the beneficiary received oral medications and had stable vital signs. Regarding rehabilitation services, the beneficiary received physical and occupational therapy in the SNF. By the dates in question, the beneficiary was at a stand by assist to contact guard assist level with functional mobility including gait to short distances. There are no identifiable skilled nursing service needs. There are no remaining identifiable skilled therapy service needs. This beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 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 continued SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care beyond June 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided by a participating provider on January 19, 2021, to February 18, 2021.

You asked the Plan to waive the copayment for an office visit. You say that you do not think you are responsible for these copayments. The Plan denied your request. The Plan says the correct copayments have 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 $30 copayment for physician services/out-of-network/specialist. 

You have been asked to pay a $30 copayment for each office visit. The total amount you are being asked to pay is $150 ($30 x 5 visits = $150). The correct copayments have been applied to the services that were provided.

An office visit falls within the physician services/out-of-network/specialist 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 by a participating provider on January 19, 2021, to February 18, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on February 4, 2021.
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 if a laboratory assays two or more genes in a patient in parallel, then those two or more genes will be considered part of the same panel.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at issue in this case should be reported with CPT 81479. 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 laboratory services provided to the enrollee on February 4, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services you received on April 1, 2021.

You asked the Plan to waive the copayment for the ambulance services. You say that this transport was less than a mile and you weren't give the choice of type of transportation. You said that you believe this charge is excessive. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that because the allowed amount for this transport ($240.58) is less than your copayment obligation, you are responsible for the full allowed 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 $290 copayment for ambulance services.

You have been asked to pay a $290 copayment for the ambulance services. This copayment applies regardless of the reason for the transport and regardless of how long the trip is. 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 ambulance services you received on April 1, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on March 19, 2021 by a non-participating provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by a non-participating provider without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The referring provider is not a network provider with the Plan. The Plan had network providers available who could have provided 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 laboratory services provided on March 19, 2021 by a non-participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a non-Medicare covered determination of refractive state refraction (92015) provided on March 29, 2021.
You asked the Plan to pay for a non-Medicare covered determination of refractive state refraction (92015). You say that you would like the Plan to reconsider your request. The Plan denied your request. The Plan says on March 29, 2021 you had an eye exam and treatment for established patient (92014) with a $20 copayment. During this visit you also received a review of your current medications (G8427) and a computerized ophthalmic diagnostic imaging (92134) with a $0 copayment. You also received a non-Medicare covered determination of refractive state refraction (92015) with a $45 charge. No payment was made under the Plan's supplemental vision benefit as the provider is not a preferred provider within the vision plan.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file and the Plan's rules. The file shows that on March 29, 2021 you received a non-Medicare covered determination of refractive state refraction (92015) with a $45 charge. No payment was made under the Plan's supplemental vision benefit as the provider is not a preferred provider within the vision plan. Therefore, we decided that the Plan does not have to pay for a non-Medicare covered determination of refractive state refraction (92015) provided on March 29, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on June 26, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. 

We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on June 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral periapical - each additional film (D0230) intraoral - periapical first film (D0220) emergency palliative treatment (D9110) Crown-porcelain/ceramic (D2740) provided December 11, 2020 to February 3, 2021.

You asked the Plan to pay for the dental services. You say that you had a medical problem which prompted you to call your dentist. You were having problems eating and dealing with pain. Please reconsider granting your appeal. The Plan denied your request. The Plan says the services are not covered as the enrollee does not have dental coverage.

Medicare generally does not cover dental services. The Plan follows the same rule. 

The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth.

These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the intraoral periapical - each additional film (D0230) intraoral - periapical first film (D0220) emergency palliative treatment (D9110) Crown-porcelain/ceramic (D2740) provided December 11, 2020 to February 3, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for home health aide services provided from January 3, 2021, through January 11, 2021.
You asked the Plan to pay for home health aide services. You say that the services were not related to the hospice terminal condition. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for home health aide services provided from January 3, 2021, through January 11, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a computed tomography (CT) scan (71250) provided on April 12, 2021.

You asked the Plan to pay for a CT scan. You say that the enrollee had multiple exams. The Plan denied your request. The Plan says this is a bundled service.

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 71250 has a bundled relationship with code 71275 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 computed tomography (CT) scan (71250) provided on April 12, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on June 26, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were billed incorrectly.
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results. We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on June 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series of x-rays (D0210) provided on May 20,
2021.

You asked the Plan to pay for the complete series of x-rays. You say that you trusted the provider to verify
your benefits before providing services. The Plan denied your request. The Plan says you previously had a
panoramic x-ray covered in 2019. You may only have one panoramic x-ray or complete series of x-rays within
5 years. Therefore, payment is denied.

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. The Plan can cover one
complete x-ray series or one panoramic x-ray every five years.

Though the Plan offers a dental benefit in excess of Medicare coverage, the x-rays are requested in a frequency
that is not covered under this benefit. Documentation shows that you previously had either a panoramic or
complete series of x-rays provided less than five years before the date in question. Therefore, we decided that
the Plan does not have to pay for the complete series of x-rays (D0210) provided on May 20, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for SNF services provided from March 3, 2021, through
March 4, 2021.
You asked the Plan to pay for the SNF services. The Plan denied your request. The Plan says skilled nursing
services when necessary, would be covered under the hospice, not Medicare Part C benefit.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services.
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore,
we decided that the Plan does not have to pay for SNF services provided from March 3, 2021, through
March 4, 2021.