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

We decided that the Plan does not have to pay for the drug testing coded 80307 and G0483 provided on December 5, 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 G0483 are not supported in the medical record. Specifically, the documentation submitted did not include a valid physician order/lab requisition form stating exactly what tests were to be performed. 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 G0483 provided on December 5, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 8 additional physical therapy visits.
You asked the Plan to pre-approve 8 additional physical therapy visits. You say that there are continued side effects from treatment that require continued care. You say that the unmanaged side effects could worsen without continued physical therapy. The Plan denied your request. The Plan says the additional visits are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 8 additional physical therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the enrollee has had extensive therapy, is able to perform self-manual lymph drainage techniques and has an independent home program in place that includes stretches and myofascial release along with compression wear. Our physician reviewer also found that the unique skills of a professional therapist are not required to safely and effectively provide ongoing treatment. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 8 additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 8 additional physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the services rendered from February 28, 2018 to March 26, 2018.
You asked the Plan to waive the copayments for these services. You say that you disagree with the charges. The Plan denied your request. The Plan says the copayments were 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 $30 copayment for each in-network Medicare-covered specialist visit and a $225 copayment for all other diagnostic and nuclear medicine radiological services.
Review of the file shows that you received outpatient hospital clinic services on February 28, 2018. You have been asked to pay a $30 copayment for these services. These services fall within the in-network Medicare-covered specialist visit benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.
The file shows that you received a sleep test on March 19, 2018. Per your contract with the Plan, there is a $225 copayment for all other diagnostic and nuclear medicine radiological services. However, the Medicare allowed amount for these services was $124.22. Given that the allowed amount was less than the $225 copayment, you have been asked to pay $124.22 for these services.
The file shows that you received outpatient hospital clinic services on March 26, 2018. You have been asked to pay a $30 copayment for these services. These services fall within the in-network Medicare-covered specialist visit benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.
The total amount you have been asked to pay for these services is $184.22. 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 copayments for the services rendered from February 28, 2018 to March 26, 2018.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the ankle arthroplasty rendered from October 24, 2019 to October 25, 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 procedure is inpatient-only.
The Plan must follow Medicare rules. The rules say that CMS does not pay for an "inpatient-only" service furnished to a person who is registered in the hospital as an outpatient. We looked at the file and Medicare rules. The services at issue are procedure code 27706. This code is an inpatient-only procedure and is not payable at the outpatient rate. Therefore, we decided that the Plan does not have to pay for the ankle arthroplasty rendered from October 24, 2019 to October 25, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital services provided from February 12, 2020 through February 14, 2020.
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you were unaware of charges for inpatient services at the hospital. The Plan denied your request. The Plan says that your copayment was assessed according to your benefit.
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 $250 copayment per day for days 1-7 of Inpatient hospital coverage. You have been asked to pay a $500 copayment for the inpatient hospital services. The inpatient hospital services fall within the days 1-7 of Inpatient hospital coverage 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 inpatient hospital services provided from February 12, 2020 through February 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist services rendered on March 17, 2020.
You asked the Plan to waive the copayment for these services. You say that you did not have a copayment prior to 2020. The Plan denied your request. The Plan says the copayment was 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 $20 copayment per visit to a specialist.
Review of the file shows that you received specialist services on March 17, 2020. You have been asked to pay a $20 copayment for these services. These services fall within the visit to a specialist benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the specialist services rendered on March 17, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the Albuterol Sulfate and Gentamicin Sulfate Ophthalmic solution provided on March 14, 2020.
You asked the Plan to pay for the Albuterol Sulfate and Gentamicin Sulfate Ophthalmic solution. You say that you cannot afford to pay for these services. The Plan denied your request. The Plan says you were in an outpatient setting, and Medicare nor the health plan cover self-administered drugs in the outpatient setting under Medicare Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the Albuterol Sulfate and Gentamicin Sulfate Ophthalmic solution provided on March 14, 2020.
Benefits for the Albuterol Sulfate and Gentamicin Sulfate Ophthalmic solution may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on March 20, 2020 through April 10, 2020.
You asked the Plan to pay for the psychotherapy services. You say that you would like reconsideration because this provider is eligible for Medicare and in-network with the Plan. The Plan denied your request. The Plan says certain Medicare Non-Par providers are not recognized as payable by Medicare.
The Plan must follow Medicare rules. Medicare rules say that Licensed Professional Counselors are not eligible to enroll in Medicare. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the psychotherapy services have not been met. Specifically, this provider's taxonomy indicates that they are a Licensed Professional Counselor. Licensed Professional Counselors are not eligible to enroll in Medicare. Therefore, we decided that the Plan does not have to pay for psychotherapy services provided on March 20, 2020 through April 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the allergy injection provided on March 12, 2020.
You asked the Plan to reduce the copayment for the allergy injection. You say that you have not been charged a copayment for allergy shots prior to 2020. 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 $20 copayment per visit to a specialist. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $20 copayment for the allergy injection.
You have been asked to pay a $8.98 copayment for the allergy injection. The allergy injection falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows the allergy injection is considered a physician service.
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 allergy injection provided on March 12, 2020.
Our decision is only about the March 12, 2020 service. If you have any questions about prior years billing, please contact the plan directly.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9328) provided on October 2, 2019 through December 23, 2019.
You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration because this infusion code is not for durable medical equipment and was not delivered to the member's home. The Plan denied your request. The Plan says CPT code S9328 is not recognized for non-participating providers.
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 indicator of I. This means that CPT code S9328 is not valid for Medicare purposes. 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 October 2, 2019 through December 23, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the paramedic intercept services (A0432) provided February 18, 2020.
You asked the Plan to pay for the paramedic intercept services. You say that you were having a heart attack and 911 was called. Two paramedics arrived along with the ambulance. You had no control over this and was surprised to get a bill. The Plan denied your request. The Plan says this service is not covered. Medicare will not pay for paramedic services if the volunteer company does not have a contract with the paramedic company.
The Plan must follow Medicare rules. The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. Medicare allows ALS paramedic intercept services only when the services are furnished under a contract with a qualified basic life support (BLS), the provision of medically necessary supplies and services, with a volunteer ambulance company. In addition, State law must not allow the volunteer ambulance company to bill for the transport or BLS services. The Plan has confirmed that paramedic company does not have a contract with the volunteer ambulance company that provided the transport services. Therefore, we decided that the Plan does not have to pay for the paramedic intercept services (A0432) provided February 18, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on October 14, 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 drug testing rendered on October 14, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the IRF admission is medically necessary. The Plan denied your request. The Plan says the enrollee's needs can be met at a different level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found based on the medical records provided the complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You may require skilled physical therapy and occupational therapy but based on the medical records provided you do not require treatment in an intensive rehabilitation therapy program. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for custom plastic eye prosthetic (V2623) fabrication and fitting of ocular conformer (V2628) provided February 10, 2020.
You asked the Plan to pay for . You say that the records provided should support the necessity of the service in dispute. The Plan denied your request. The Plan says there is insufficient documentation to corroborate the service so 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. Physicians must avoid upcoding. A HCPCS/CPT code may be reported only if all services described by that code have been performed. 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 physician order, proof of delivery, itemized delivery ticket, itemized shipping invoice or relevant medical records which support medical necessity for the supplies provided in this case. Specifically, for V2623 the documentation submitted do not indicate that prosthetic eye, plastic, custom was delivered to the enrollee on the billed date of service. The documentation also indicates that the prosthesis was delivered on 03/11/2020 which is post the billed date. For V2628, the documentation submitted do not indicate that fabrication and fitting of ocular conformer was performed on the billed date of service. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for custom plastic eye prosthetic (V2623) fabrication and fitting of ocular conformer (V2628) provided February 10, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a CT scan.
You asked the Plan to pre-approve a CT scan. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the requested CT scan is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. 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 a CT scan. Our reviewer says that the documentation does support that the requested CT scan is medically reasonable and necessary. Our physician reviewer found the enrollee has left midfoot pain. Plain x-rays show moderate degeneration of 2 and 3 TM joint of left foot. The requested CT scan is 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 a CT scan have not been met. Therefore, we decided that the Plan has to pre-approve a CT scan.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit services rendered from January 20, 2020 to January 25, 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 procedure code 99509 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. We looked at the file and Medicare rules. The provider submitted claims for procedure code 99509. 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 home visit services rendered from January 20, 2020 to January 25, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for a duplex scan of lower extremity arteries or arterial bypass grafts provided on May 4, 2020.
You asked the Plan to pay for the duplex scan of lower extremity. 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 duplex scan of lower extremity arteries or arterial bypass grafts provided on May 4, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on November 1, 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 drug testing rendered on November 1, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the colonoscopy (45385) provided on January 10, 2020 by an out of network (OON) provider.
You asked the Plan to pay for an OON colonoscopy. You say that this was medically necessary. The Plan denied your request. The Plan says this was 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 colonoscopy (45385) provided on January 10, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis rendered on September 20, 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. The rules say that a supplier must have an order from the treating physician before dispensing any DMEPOS item to a beneficiary. We looked at the file and Medicare rules. There is no valid physician order for the DME. 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 lumbar-sacral orthosis rendered on September 20, 2019.