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

We decided that the Plan does not have to pay for services provided to the enrollee from July 2, 2019 to July 8, 2019 and billed under code S9348.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says per the 2019 National Physician Fee Schedule Relative Value July Release, CPT code S9348 has a status code of I which is not valid 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. In this case, code S9348 cannot be paid as billed due to the status indicator of "I". Based on this information, we decided that Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for services provided to the enrollee from July 2, 2019 to July 8, 2019 and billed under code S9348.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 3, 2019 by out of network provider. You asked the Plan to pay for the office visit. You say that you are in-network with the Plan. The Plan denied your request. The Plan says the information received did not show that the service met exceptions for the use of a non-network provider, that an authorization was obtained before the service was rendered or that the service met criteria for continuity of care coverage.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 3, 2019 by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided to the enrollee on June 26, 2019. You asked the Plan to pay for this service. You say that this claim should be paid.The Plan denied your request. The Plan says the enrollee did not have prior authorization for 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 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 medical services provided to the enrollee on June 26, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical assistant services provided for closed treatment of a shoulder dislocation on May 23, 2019.You asked the Plan to pay for the surgical assistant services. You say that this provider played a major role in this procedure and should be reimbursed for the services rendered.The Plan denied your request. The Plan says Medicare does not pay for surgical assistance with this procedure.The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for CPT code 23655. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the surgical assistant services have not been met.Therefore, we decided that the Plan does not have to pay for the surgical assistant services provided for closed treatment of a shoulder dislocation on May 23, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe infusion of chemotherapy, denosumab injection and trastuzumabinjection provided on July 12, 2019.You asked the Plan to waive the coinsurance for these services. You say that  The Plan denied your request. The Plan says that cost sharing is a contractual obligation under the plan and cannot be waived.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 20% coinsurance for Medicare Part B Prescription Drugs. You have been asked to pay 20% coinsurance for these services. These services fall within the Medicare Part B Prescription Drugs 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 forthe infusion of chemotherapy, denosumab injection and trastuzumab injection provided on July 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital physician services provided from August 6, 2019 to August 7, 2019.
You asked the Plan to pay for physician services. You say that you are appealing with medical records. The Plan denied your request. The Plan says the denial of payment for these services is correct, because the enrollee was enrolled in a hospice program on these dates of service and therefore the Plan is not responsible for payment.
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 inpatient hospital physician services provided from August 6, 2019 to August 7, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee on July 9, 2019. You asked the Plan to pay for this claim. You say that this service was medically necessary.The Plan denied your request. The Plan says the enrollee did not have prior authorization to receive care from an out of network provider. 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 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 to the enrollee on July 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 5, 2019. You asked the Plan to pay fora specialist office visit. You say that the enrollee does not need prior authorization.The Plan denied your request. The Plan says prior authorization is required prior to service.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 incases 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. The enrollee does not have out-of-network benefits. 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 5, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for manual therapy (97140), a physical therapy evaluation (97161), and electrical stimulation (G0283) provided on July 20, 2019.You asked the Plan to pay for physical therapy services. You say that these services are covered by Medicare.The Plan denied your request. The Plan says unauthorized services from out-of-network providers are not covered. 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 manual therapy (97140), a physical therapy evaluation (97161), and electrical stimulation (G0283) provided on July 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic physician services provided to the enrollee and billed under codes 97012, 97140-59 and 97032.
You asked the Plan to pay for codes 97012, 97140-59 and 97032. You say that this claim should be paid. The Plan denied your request. The Plan says ancillary services by chiropractors are not a Medicare benefit. The plan states what while code 98940 will be paid, the denial for procedure codes 97012, 97140-59 and 97032 for dates of service June 14, 2019 shall remain denied.
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 services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for chiropractic physician services provided to the enrollee and billed under codes 97012, 97140-59 and 97032.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the U-Step Walker purchased on a website on May 2, 2019. You asked the Plan to reimburse you for the U-Step Walker. You say that you need the walker and were unaware the supplier was not Medicare certified.The Plan denied your request. The Plan says the website is not a Medicare certified supplier and therefore the walker is not reimbursable.The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or provider who has opted out of the program except in cases involving emergencies or urgently needed care. The item at issue in this appeal was provided in a non-urgent, non-emergent situation. This provider has opted out of the Medicare program. The file shows that the website comentered into a private contract with you regarding payment. Therefore, we decided that the Plan does not have to reimburse you for the U-Step Walker purchased on May 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 24, 2019 by out of network provider.
You asked the Plan to pay for physician services. You say that you would like the claim reprocessed and paid. The Plan denied your request. The Plan says no prior authorization was obtained; therefore, the claim has been correctly denied for payment.
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 24, 2019 by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided on May 15, 2019.You asked the Plan to waive the copayment for specialist visit. You say that you have never had to pay a copayment to see this provider before.The Plan denied your request. The Plan says the copayment amount you are being charged is correct.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 $49 copayment for specialist visit. You have been asked to pay $49 copayment for specialist visit. 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 foran office visit provided on May 15, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided to the enrollee on February 26, 2019. You asked the Plan to pay for this service. You say that this claim should be paid.The Plan denied your request. The Plan says the enrollee did not have prior authorization for 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 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 lab services provided to the enrollee on February 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the intermittent urinary catheters rendered on July 9, 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 there is no valid proof of delivery. The Plan must follow Medicare rules. The rules say that all DMEPOS suppliers are required to maintain proof of delivery. We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. 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 intermittent urinary catheters rendered on July 9, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from July 15, 2019 through July 20, 2019.You asked the Plan to waive the copayment for an inpatient hospital stay. You say that your first hospital stay was from June 23, 2019 through June 30, 2019. You say that you were back in the hospital with complications from July 15, 2019 through July 20, 2019. You further say that you feel because you were admitted within 3 weeks for the same condition that it should be considered one event.The Plan denied your request. The Plan says inpatient hospital care has a $295 copayment per day for days 1-5.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 $295 copayment per day for days 1-5 for inpatient hospital care. You have been asked to pay a $295 copayment per day for days 1-5 for an inpatient hospital stay. This service falls within the inpatient hospital care benefit category(5 days x $295 = $1,475).Your contract with the plan states that the day before you are discharged is your last inpatient day. This means that your first stay is not a continuation of your second stay and therefore cannot be considered one event.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 foran inpatient hospital stay provided from July 15, 2019 through July 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe office visit provided on September 3, 2019 by the out of network provider.You asked the Plan to pay forthe physician services. You say that the provider accepted your insurance information. You also say that the provider did not advise that they were out of network.The Plan denied your request. The Plan says authorization was not obtained before you received the service.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 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 thatthe Plan does not have to pay forthe office visit provided on September 3, 2019 by the out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge day management, more than 30 minutes (99239) provided on April 5, 2019.
You asked the Plan to pay for the hospital discharge day management. You say that the records provided should support the necessity of the services in dispute. The Plan denied your request. The Plan says there is insufficient documentation to corroborate the service to confirm that the Medicare coverage criteria has been met.
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 99233 is the hospital discharge day management, more than 30 minutes. We find that CPT code 99233 is not supported in the medical record. Specifically, the submitted discharge summary does not support hospital discharge day management of more than 30 minutes was performed. Based on this information, we decided that Medicare rules for coverage of the hospital discharge day management have not been met. Therefore, we decided that the Plan does not have to pay for the hospital discharge day management, more than 30 minutes (99239) provided on April 5, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered to the enrollee on July 24, 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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 for the laboratory services rendered to the enrollee on July 24, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services rendered to the enrollee on August 6, 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 95937 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 95937 is neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method. We find that CPT code 95937 is not supported in the medical record. Specifically, there is no documentation of neuromuscular junction testing being performed. 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 for the testing services rendered to the enrollee on August 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the diabetic supplies rendered to the enrollee from July 23, 2019 to October 11, 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 there is no valid proof of delivery.
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS suppliers are required to maintain proof of delivery. We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. 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 for the diabetic supplies rendered to the enrollee from July 23, 2019 to October 11, 2019.