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

We decided that the Plan does not have to waive the copays for the medical services you received from October
23, 2019 to November 21, 2019.
You asked the Plan to waive the copays for the services provided. The Plan denied your request. The Plan says
the copays were applied based on your plan benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance).
You have been asked to pay a $295 copay for the outpatient hospital services, and a $45 copay for specialist
services The services fall within the outpatient hospital and physician services benefit categories. 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 copays for the medical services you received from October 23, 2019 to November
21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nurse practitioner services provided on November 30, 2019.You asked the Plan to pay for the nurse practitioner services. The Plan denied your request. The Plan says there is no valid referral for this serviceMedicare 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 servicesat 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 nurse practitioner services provided on November 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home health services provided to the enrollee from October 31, 2019.You asked the Plan to pay forhome health services. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says payment is not allowed for this service because it is not appropriate for the type of bill submitted.The Plan must follow Medicare rules. The rules say that certain data elements on the RAPand 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, this claim was submitted with an inappropriate type of bill. Home health claims must be submitted with TOB 0329. Therefore, we decided that the Plan does not have to pay forthe home health services provided to the enrollee from October 31, 2019
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endovenous radiofrequency ablation therapy for the
enrollee.
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your
request. The Plan says the records show clinically significant or symptomatic peripheral arterial disease.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the therapy. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found there are inconsistencies with respect to the enrollee's symptoms. It is noted that the enrollee complains
of chest pain, dizziness with walking, and leg cramps with occasional leg pain. The enrollee specifically denies leg
edema denies heaviness, denies fatigue, denies restless legs, denies itching and burning of the lower
extremities. In other portions the medical history they complain of all these leg symptoms. Enrollee denies
hypertension but is on antihypertensive medication. On physical examination the enrollee has no edema bilaterally. The
enrollee has a history of carotid artery stenosis and peripheral vascular disease as well as atrial fibrillation and
is on anticoagulation. Patient also has a history of hyperlipidemia including a history of hypertension. Their
lower extremity claudication/PAD was severe enough to warrant angiography that demonstrated disease. Enrollee is
apparently status post venous ablations and is pending more ablations per medical record. Specifically, the
patient has a criteria exclusion in that there is a history of significant peripheral artery disease. Additionally,
does not meet criteria as the documentation does not satisfactory demonstrate that the patient is having activity
limiting symptoms attributable to her residual varicose veins.
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 therapy have not been met. Therefore, we decided that the Plan does not
have to pre-approve endovenous radiofrequency ablation therapy for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9328) provided on November 25, 2019 through December 2, 2019.
You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration because per CMS, CPT code S9328 is valid. The Plan denied your request. The Plan says CPT code S9328 has a status code of I which is invalid for Medicare purposes.
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 CPT code S9328 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code S9328 has a status code of I. This means that CPT code S9328 is not valid for Medicare purpose. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9328) provided on November 25, 2019 through December 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 27, 2019 by an out of network (OON) provider.
You asked the Plan to pay for physician services. You say that you are appealing with records. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and the referring physician is also out-of-network with the Plan.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on September 27, 2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided to the enrollee by an out of network (OON) provider.
You asked the Plan to pre-approve the OON services. You say that endovenous therapy without adjunctive therapy will result in incomplete treatment. The Plan denied your request. The Plan says in-network providers can provide the requested services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve the medical services to be provided to the enrollee by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 9, 2019 by an out of network (OON) provider.You asked the Plan to pay for outpatient clinic visit. You say that you are requesting payment.The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and prior authorization was not obtained.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay for the medical services provided on July 9, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the perfusionist services provided to enrollee on October 30, 2019.You asked the Plan to pay for the services provided. You say that the charges are for the perfusionist that set up and operated the heart-lung machine for the enrollee's surgery.The Plan denied your request. The Plan says payment for this service is the responsibility of the facility.The plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility for services furnished to a beneficiary.We looked at the file and Medicare rules. The facility must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. This service was provided via arrangement of the facility. Payment for this service would have been included under the facility claim. Payment to you for this service is the responsibility of the facility. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the perfusionist services provided to enrollee on October 30, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a drug test provided on November 15, 2019.You asked the Plan to pay for the drug test. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.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 a drug test provided on November 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the perfusionist services provided to the enrollee on December 10, 2019.
You asked the Plan to pay for the services provided. You say that the charges are for the perfusionist that set up and operated the heart-lung machine for the enrollee's surgery. The Plan denied your request. The Plan says payment for this service is the responsibility of the vendor.
The plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility for services furnished to a beneficiary. We looked at the file and Medicare rules. The facility must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. This service was provided via arrangement of the facility. Payment for this service would have been included under the facility claim. Payment to you for this service is the responsibility of the facility. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the perfusionist services provided to the enrollee on December 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services (CPT 95937) provided on August 22, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the billed service cannot be verified.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 95937 is "Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method".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 use of CPT code 95937 is not supported by the records provided. Our coding reviewer found that the medical records submitted do not include documentation of a Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method being performed on August 22, 2019. The medical records document that Train of Four Testing/Monitoring was performed on August 22, 2019. It is inappropriate to use CPT code 95937 for Train of Four testing.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 forthe services (CPT 95937) provided on August 22, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy provided on December 3, 2019.You asked the Plan to waive the copayment for the colonoscopy. You say that there is a $0 copayment for a preventive colonoscopy. 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 $100 copayment for outpatient surgery at hospital outpatient facilities and ambulatory surgical centers. You have been asked to pay a $100 copayment for the colonoscopy. The colonoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The medical records show polyps were removed during the colonoscopy which makes the colonoscopy diagnostic in nature. This means that you have been asked to paythe 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 colonoscopy providedon December 3, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home health services rendered to enrollee from June 21, 2019 to August 19, 2019.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 claim was not billed correctly.The Plan must follow Medicare rules. The rules say that a treatment authorization code is required forhome health claims.We looked at the file and Medicare rules. The home health claims were not billed with the required treatment authorization code. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay forthe home health services rendered to enrollee from June 21, 2019 to August 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered to you by a chiropractor on July 16, 2019 to August 6, 2019.
You asked the Plan to pay for these services. You say that you assumed the doctor was out-of-network. The Plan denied your request. The Plan says the services are not covered when billed by a chiropractor.
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 file shows that the provider submitted a claim for procedure codes 97140 (manual therapy) and 99201 (office visit). The claims were not denied due to network status, but because the services are not covered when performed by a chiropractor. Therefore, we decided that the Plan does not have to pay for the services rendered to you by a chiropractor on July 16, 2019 to August 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on December 6, 2019.You asked the Plan to waive the copayment for the office visit. You say that you were informed at the office visit that the provider was leaving. You say that you should not have to pay for this appointment.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 each Medicare-covered specialist visit. You have been asked to pay a $35 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment for the office visit provided on December 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the annual wellness visit rendered to you on December 12, 2019.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 exceeded the benefit limit.The Plan must follow Medicare rules. Medicare rules say that an annual wellness visit is covered once every 12 months.We looked at the file and Medicare rules. The file shows that you previously received an annual wellness visit on January 21, 2019 for which the Plan approved and paid. The annual wellness visit on December 12, 2019 was performed less than 12 months than your previously covered exam.Therefore, we decided that the Plan does not have to pay for the annual wellness visit rendered to you on December 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider from October 25, 2019, to November 27, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the services were not authorized.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 forthe medical services provided to the enrollee by an out-of-network provider from October 25, 2019, to November 27, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a diagnostic ultrasound.
You asked the Plan to pre-approve the ultrasound. You say that this is medically necessary, as you want to have your arteries checked. The Plan denied your request. The Plan says no physician or practitioner has ordered a diagnostic ultrasound of any type.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the ultrasound. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found an order for a diagnostic ultrasound is necessary for all ultrasound cases to be done at any hospital or imaging center. CMS does not reimburse for any study without a valid order and reason for the request. 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 ultrasound have not been met. Therefore, we decided that the Plan does not have to pre-approve a diagnostic ultrasound.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a Nitro rollator brand rolling walker.
You asked the Plan to pre-approve the Nitro Rollator. You say that you feel that you should be allowed to get the walker you feel suits you best. The Plan denied your request. The Plan says that the requested brand is not shown to be medically necessary. The plan will only cover the standard walker and will not pay more for this brand.
The Plan must follow Medicare rules. Medicare rules say that plans may restrict coverage of DME to certain brands only if this limitation is disclosed in the EOC. In this case, there is no notation in the EOC that coverage for DME generally or walkers specifically would be limited to the least expensive brand. The Plan has indicated that its network supplier is able to provide the requested brand and that the brand requested is described by the same HCPCS code as the walker being offered by the Plan. We find no provision in the contract which would prevent the enrollee from receiving coverage for the requested brand of walker. Therefore, we decided that the Plan has to pre-approve a Nitro rollator brand rolling walker.