Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for the Mohs micrographic surgery services provided on July 8, 2019.
You asked the Plan to pay for the Mohs micrographic surgery services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the services were billed with diagnosis codes that are not covered.
The Plan must follow Medicare rules. Medicare rules say that Mohs Micrographic Surgery is covered for certain indications.
Review of the file shows that the plan uses Local Coverage Determination (LCD) L36423 and Local Coverage Article (LCA) A57767 to support their denial. However, both of these documents are not valid for the enrollee or the provider's state of NE. Therefore, these documents cannot be used to substantiate our decision. Also, Local Coverage Article A57477 for billing and coding cannot be used as it was not valid for this date of service in question.
In addition, the plan states that the claim was not billed with appropriate diagnosis codes. While LCD L35494 does give a list of diagnosis codes that support medical necessity, the LCD does not state that any code not listed is not medically necessary. Also, the LCD does have diagnosis code C44.209 (Unspecified malignant neoplasm of skin of left ear and external auricular canal) listed as a code that is considered medically necessary. Therefore, the plan has not substantiated their denial with valid arguments. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Mohs micrographic surgery services have been met. Therefore, we decided that the Plan has to pay for the Mohs micrographic surgery services provided on July 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 10, 2019 by out of network provider
You asked the Plan to pay for the office visit (99205). You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says prior authorization was not obtained by the provider or facility.
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 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the echocardiography provided on August 19, 2019.
You asked the Plan to reduce the copayment for the echocardiography. You say that you did not have the heart ultrasound done in a hospital setting. You say you paid $50 at the visit and do not believe you should pay an additional $50. 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 a $100 copayment for each Medicare-covered diagnostic procedures and tests for services in an in-network outpatient hospital.
You have been asked to a $100 copayment for the echocardiography. The echocardiography falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows you were billed by an outpatient hospital.
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 reduce the copayment for the echocardiography provided on August 19, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for an alcohol screen (80320) provided on July 6, 2019. 
 
You asked the Plan to pay for the alcohol screen. You say that the hospital should not be penalized because the physician did not obtain authorization. The Plan denied your request. The Plan says this code is not recognized by OPPS and an alternate code for the same service may be available per Medicare guidelines. 
 
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 80320 is not supported in the record. Specifically, per OPPS, 80320 has a status indicator of B. This means that 80320 is not recognized by OPPS when submitted on an outpatient hospital Part B bill type (12x and 13x). Based on this information, we decided that Medicare rules for coverage of the alcohol screen have not been met. Therefore, we decided that the Plan does not have to pay for an alcohol screen (80320) provided on July 6, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the bone removal and anesthesia.
You asked the Plan to pre-approve the bone removal and anesthesia. You say that you were informed this is the only way for you to obtain dentures. You say that you are not able to eat and cannot afford it yourself. The Plan denied your request. The Plan says these are not covered benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the bone removal and anesthesia.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Accu-Chek Aviva blood glucose test strips for the
enrollee.
You asked the Plan to pre-approve these services. The Plan denied your request. The Plan says that we have not
received information you cannot use the covered brand.
The Plan must follow Medicare rules. Medicare rules say that plans may limit enrollees to preferred providers.
The items at issue are Accu-Chek Aviva blood glucose test strips. Accu-Chek Aviva is not a preferred provider
with the Plan for diabetic supplies. One Touch is the preferred providers. Therefore, we decided that the Plan
does not have to pre-approve Accu-Chek Aviva blood glucose test strips for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient consultation rendered to the enrollee on July 5, 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 procedure code 99255 is not covered.
The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid for Medicare purposes. The provider submitted a claim for procedure code 99255 (inpatient consultation). This code has a status indicator of I and is not valid for Medicare purposes. Therefore, we decided that the Plan does not have to pay for the inpatient consultation rendered to the enrollee on July 5, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on May 6, 2019.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order/lab requisition.
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 a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on May 6, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient lab work provided on May 15, 2019 by an out of network provider.
You asked the Plan to pay for outpatient lab work. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the referring provider is also out-of-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 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 lab work provided on May 15, 2019 by the out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for blood glucose monitor with integrated voice synthesizer to be provided on August 13, 2019.
You asked the Plan to pay for BG monitor with integrated voice synthesizer. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says the records do not support the supplies 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 does not contain a valid delivery ticket and proof of delivery for the supplies provided in this case. The delivery ticket 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 proof of delivery is not itemized to indicate the specific supplies. Therefore, we decided that the Plan does not have to pay for blood glucose monitor with integrated voice synthesizer to be provided on August 13, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the mouth-guard for TMJ.
You asked the Plan to pre-approve the mouth-guard for TMJ. You say that it is medically necessary to receive
this treatment. The Plan denied your request. The Plan says the service is not covered benefit by Medicare.
Medicare generally does not cover dental services. The Plan follows the same rule.
The services you are asking the Plan to pre-approve 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 pre-approve the mouth-guard for
TMJ.
Appeal type: Practitioner Services
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 July 31, 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 medically 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.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a Duplex Scan (93925) provided on August 13, 2019.
You asked the Plan to pay for the Duplex Scan. You say that the services were medically necessary. The Plan denied your request. The Plan says the diagnosis code provided does not support the services at issue.
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 93925 is not supported in the medical record. Specifically, diagnosis code R60.0 is not an indicated diagnosis code for performing a duplex scan of lower extremity arteries. Based on this information, we decided that Medicare rules for coverage of the Duplex Scan have not been met. Therefore, we decided that the Plan does not have to pay for a Duplex Scan (93925) provided on August 13, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the diabetic supplies provided to the enrollee from August 12, 2019 to October 31, 2019.
You asked the Plan to pay for the diabetic supplies. The Plan denied your request. The Plan says that there is no valid proof of delivery
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The tracking ticket does not include the items supplied and the delivery ticket does not include a tracking number to confirm it was delivered. Therefore, we decided that the Plan does not have to pay for the diabetic supplies provided to the enrollee from August 12, 2019 to October 31, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the first hour of critical care management services (99291) provided on June 17, 2018 through June 18, 2018.
You asked the Plan to pay for the critical care management services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation does not include the time spent providing this service; therefore, the billed Critical Care Evaluation and Management code 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 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes. We find that CPT code 99291 is not supported in the record. Specifically, the record does not indicate the amount of time that critical care services were rendered. Based on this information, we decided that Medicare rules for coverage of the critical care management services have not been met. Therefore, we decided that the Plan does not have to pay for the first hour of critical care management services (99291) provided on June 17, 2018 through June 18, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bed side rails, full length (E0310).
You asked the Plan to pre-approve the bed side rails. You say that the enrollee is deteriorating and needs to be in hospice care and you need the bed rails for fall prevention. The Plan denied your request. The Plan says side rails used as a restraint to prevent falls or wandering will be not be covered.
The Plan covers all items that Medicare covers. Medicare rules state that bed rails are not covered because they are not primarily medical in nature. While a bed rail may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve bed side rails, full length (E0310).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a pneumatic compression device and leg appliances
You asked the Plan to provide a pneumatic compression device (E0652) and leg appliances (E0669). You say
that you are the only one that carries the Flexitouch Pneumatic Compression Device. The Plan denied your
request. The Plan says the device is not covered for the treatment of lymphedema of the extremity alone.
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 order is for treatment of
lymphedema extending onto the chest, truck or abdomen. Therefore, we decided that the Plan does not have to
provide a pneumatic compression device and leg appliances.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 2, 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 were rendered by a non-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 for the medical services provided on August 2, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the diabetic supplies provided to the enrollee from August
10, 2019 through October 29, 2019.
You asked the Plan to pay for the diabetic supplies. The Plan denied your request. The Plan says that there is no
valid proof of delivery.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a
physician order and proof of delivery.
The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the
items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in
this case. The tracking ticket does not include the items supplied and the delivery ticket does not include a
tracking number to confirm it was delivered. Therefore, we decided that the Plan does not have to pay for the
diabetic supplies provided to the enrollee from August 10, 2019 through October 29, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for pathology services provided on April 30, 2019.
You asked the Plan to pay for the pathology services. The Plan denied your request. The Plan says nonemergent,
non-urgent services with out-of-network providers require prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we
decided that the Plan does not have to pay for pathology services provided on April 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nursing facility services provided on by out of network provider
You asked the Plan to pay for nursing facility services. You say that the facility requested the enrollee to be seen by one of your nurse practitioners. The Plan denied your request. The Plan says no prior authorization was obtained for these 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 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 nursing facility services
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on April 9, 2019.
You asked the Plan to pay for the laboratory 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 are not covered.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on April 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 4, 2019 by the out of network provider.
You asked the Plan to pay for wound care. You say that the services rendered were medically necessary. The Plan denied your request. The Plan says the wound care 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 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 4, 2019 by the out of network provider.