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

We decided that the Plan does not have to pay for the automatic external defibrillator provided on November 4,
2019 and December 4, 2019 by an out of network provider.
You asked the Plan to pay for the automatic external defibrillator. You say that the Plan should pay this claim.
The Plan denied your request. The Plan says you are not a network provider and the service was not urgent,
emergent, or approved.
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 item at issue in this appeal. The Plan did not pre-approve the item at issue. We
found no exception that would require the Plan to pay for this item. Therefore, we decided that the Plan does
not have to pay for the automatic external defibrillator provided on November 4, 2019 and December 4, 2019
by an out of network provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the swallowing function test rendered on January 6, 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 separately payable.
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 22 for
outpatient hospital; however, the file shows that the services were performed while the enrollee was inpatient.
Therefore, we decided that the Plan does not have to pay for the swallowing function test rendered on January
6, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to reimburse the coinsurance for a colonoscopy provided on December
20, 2018.
You asked the Plan to reimburse the coinsurance for a colonoscopy. You say that you disagree with the
reimbursement amount. The Plan denied your request. The Plan says the claims were processed correctly and
the enrollee is being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees
must pay 20% coinsurance for out-of-network outpatient surgery, including services provided at hospital
outpatient facilities and ambulatory surgical centers.
The enrollee received a colonoscopy from an out-of-network provider on December 20, 2018. Therefore, the
enrollee is responsible to pay their share of the out-of-network cost-sharing charges. The total allowed amount
is $598.43 and 20% of that is $119.69.
The enrollee has been asked to pay the total coinsurance amount of $119.69 for a colonoscopy. A colonoscopy
falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory
surgical centers benefit category. This means that the enrollee has been asked to pay the correct amount based
on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon
enrolling in the Plan. Therefore, we decided that the Plan does not have to reimburse the coinsurance for a
colonoscopy provided on December 20, 2018.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for electrical stimulation therapy services (HCPCS G0283) provided to the enrollee from January 2, 2020 to January 20, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the denied code always requires a therapy modifier. 
 
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 HCPCS code G0283 is "Electrical stimulation (unattended), to one or more areas for indication(s) other than wound care, as part of a therapy plan of care." 
 
We asked our coding reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our coding reviewer found the documentation submitted was reviewed and HCPCS code G0283 requires a modifier (GN, GO, GP) per Medicare guidelines. 
 
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 electrical stimulation therapy services (HCPCS G0283) provided to the enrollee from January 2, 2020 to January 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility care (99307) provided on December 23, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for OON nursing facility care. You say that these services were medically necessary. The Plan denied your request. The Plan says these 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 nursing facility care (99307) provided on December 23, 2019 by an out of network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided from October 21, 2019 to
November 15, 2019 by a provider that does not participate in Medicare.
You asked the Plan to pay for home health services. You say that this was medically necessary and a covered
benefit. The Plan denied your request. The Plan says the provider in question does not participate in Medicare.
The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for
services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare
program.
We looked at the file and Medicare rules. The provider you received these services from does not participate in
Medicare, meaning these services are not covered. Based on this information, we decided that Medicare rules
for coverage of home health services have not been met. Therefore, we decided that the Plan does not have to
pay for home health services provided from October 21, 2019 to November 15, 2019 by a provider that does
not participate in Medicare.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the deductible for the arthrocentesis procedures provided on February 5, 2020.
You asked the Plan to reduce the deductible for the arthrocentesis procedures. You say that you would like the deductible amounts reduced to the same price. 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. Your contract with the Plan says that there is a $750 deductible that applies towards outpatient surgeries. The arthrocentesis procedures you asked the Plan to reduce the deductible for falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible that applies towards outpatient surgery. This cost sharing is a contractual obligation that had not been met at the time the arthrocentesis procedures were received on February 5, 2020. Therefore, we decided that the Plan does not have to reduce the deductible for the arthrocentesis procedures provided on February 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on February 19, 2020.
You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says
non-emergent, 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 a domiciliary, rest home visit provided on February 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the ostomy supplies provided on January 24, 2020 to February 29, 2020. 
 
You asked the Plan to waive the coinsurance for the ostomy supplies. You say that you have never had to pay for ostomy supplies before. 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 20% coinsurance for prosthetic devices and medical supplies.  
 
You have been asked to pay $116.31 which is 20% of the allowed amount for the ostomy supplies on each date of service. The allowed amount is $581.56. ($581.56 x 20% = $116.31). The ostomy supplies fall within the "Prosthetic devices and related supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the ostomy supplies provided on January 24, 2020 to February 29, 2020. 
 
Our decision is only about the 2020 services. If you have any questions about prior years billing, please contact the plan directly.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on January 22, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you called and verified this provider was in-network. The Plan says that opting out means the provider has signed an agreement to be excluded from any Medicare program, including Medicare Advantage Plans. The Plan denied your request. The Plan says the provider opted out of Medicare on October 1, 2019. 
 
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 an office visit provided on January 22, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded 80307 and G0482 
 
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
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 codes 80307 and G0482 are not supported in the medical record. Specifically, the documentation does not support any evidence of an established relationship between the member and the ordering physician. There were no claims submitted for an evaluation and management service. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded 80307 and G0482
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled therapy services rendered from November 5, 2019 to November 8, 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 claims were not billed with the required G-code/modifier information. 
 
The Plan must follow Medicare rules. The rules say that each reported functional G-code must contain a functional severity modifier when billing for Part B rehabilitation services. 
 
We looked at the file and Medicare rules. The file shows that the rehabilitation services were not billed with the required functional G-codes. 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 skilled therapy services rendered from November 5, 2019 to November 8, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from
November 11, 2019 to November 30, 2019.
You asked the Plan to pay for home health services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services were billed incorrectly.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must
be completed for home health care services to be covered.
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that
Medicare rules for completing the claim for home health services have not been met. Specifically, a required
treatment authorization code (TAC) was not included in box 63 of the claim. A TAC is a required data element
for home health services. Therefore, we decided that the Plan does not have to pay for the home health services
provided to the enrollee from November 11, 2019 to November 30, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded 80307 and G0482 provided on
October 21, 2019.
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 codes 80307 and G0482 are not supported in the medical record. Specifically, the
documentation does not support evidence of an established relationship between the member and the ordering
physician. Based on this information, we decided that Medicare rules for coverage of the drug testing have not
been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded 80307 and
G0482 provided on October 21, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion services provided to the enrollee from
November 12, 2019 to November 19, 2019 and billed under code S9328.
You asked the Plan to pay for code S9328 as billed. You say that this claim should be paid. The Plan denied
your request. The Plan says code S9328 has a status code indicator that does not allow payment on Medicare
claims.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate codes. In this case, the code billed has a status code
indicator of "I" which that does not allow payment on Medicare claims. Therefore, we decided that the Plan
does not have to pay for home infusion services provided to the enrollee from November 12, 2019 to
November 19, 2019 and billed under code S9328.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-ofnetwork
provider on January 10, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network
deficiency 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 services at issue in this appeal. The Plan did not pre-approve the services at
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that
the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider
on January 10, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computer-assisted navigation.
You asked the Plan to pre-approve computer-assisted navigation and total knee arthroplasty. The Plan denied
your request. The Plan says while the total knee arthroplasty was approved, computer-assisted navigation is not
covered by Medicare.
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 computerassisted
navigation. Our reviewer says that medical necessity for computer-assisted navigation has not been
established. Our physician reviewer says that under consideration is a request for computer-assisted navigation
for the left total knee arthroplasty. The enrollee's appeal indicates that the orthopedic physician utilizes
computer-assisted navigation for his procedure. She cited supportive literature from 2012 and 2013 and stated
she wanted the best possible result from her total knee arthroplasty and to avoid a future revision. Current 2019
and 2020 evidence based medical literature do not support the routine use of computer-assisted navigated total
knee arthroplasty over conventional total knee arthroplasty as yielding better results in the ultimate clinical
outcomes (specifically regarding pain relief and functionality.) There is no compelling rationale presented or
extenuating circumstances noted to support the medical necessity of computer-assisted navigation over
conventional total knee arthroplasty. Therefore, this request for computer-assisted navigation for left total knee
arthroplasty would be considered investigational in nature, and not reasonable and medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of computer-assisted navigation. We note the Plan approved total knee
arthroplasty have not been met. Therefore, we decided that the Plan does not have to pre-approve computerassisted
navigation and total knee arthroplasty for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Urinary Pathogens Molecular Panel provided to the
enrollee on August 5, 2019.
You asked the Plan to pay for the panel. You say that the services were medically necessary and essential to the
enrollee's care. The Plan denied your request. The Plan says experimental or investigational services are not
covered.
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 pay for the panel. Our reviewer says that the
services at issue in this case are not considered medically reasonable and necessary in this case. Our physician
reviewer found the documentation is silent as to what symptoms the enrollee was having or what examination
findings were identified at the time of service. The enrollee apparently had a standard urinalysis, which was
suspicious for a UTI. There is no documentation to support why the enrollee could not have been
presumptively treated pending the results of standard culture and sensitivity testing. There is no documentation
to explain why DNA/RNA identification was medically necessary to treat or manage the enrollee's condition.
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 panel have not been met. Therefore, we decided that the Plan does not have
to pay for the Urinary Pathogens Molecular Panel provided to the enrollee on August 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for specialist services provided on December 12, 2019 by an out
of network (OON) provider.
You asked the Plan to pay for specialist office visit. 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.
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 specialist services provided on December 12, 2019
by an out of network (OON) provider.