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

We decided that the Plan does not have to pay forthe medical services provided on October8, 2018 by out of network provider,.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services were rendered by a non-participating providerwithout 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 theitem/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 forthe medical services provided on October 8, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and arthrocentesis provided by out of network provider.
You asked the Plan to pay for the office visit and arthrocentesis. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
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 office visit and arthrocentesis provided by out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the next generation sequencing services provided by out of network provider.
You asked the Plan to pay for the next generation sequencing services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
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 next generation sequencing services provided by out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for bilateral ankle foot orthoses (L1971) provided to the enrollee on March 27, 2019.You asked the Plan to pay for the orthoses. You say that the durable medical equipment is medically necessary.The Plan denied your request. The Plan says the documentation indicates services are not necessary for treatment of the enrollee's condition.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 orthoses. Our reviewer says that the enrollee does not meet criteria for the orthoses ordered. Our physician reviewer found the documentation in the case file does not support that the requested ankle/foot orthoses were medically reasonable and necessary for the enrollee in this case, according to the criteria established by the LCD. A physical examination of the ankles and feet would reasonably be required to adequately assess whether the coverage criteria were met. The documentation does not support that the ankle/foot orthoses were medically reasonable and necessary in this case, as there is no documentation of a credible physical examination of the ankles and feet.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 orthoses have not been met.Therefore, we decided that the Plan does not have to pay for bilateral ankle foot orthoses (L1971) provided to the enrollee on March 27, 2019
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan provided.
You asked the Plan to waive the copayment for a CT scan. You say that you do not feel like you should have to pay for this. You say that your doctor is monitoring nodules on your lungs. The Plan denied your request. The Plan says the correct copayment has been applied.
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 $125 copayment for outpatient diagnostic tests/network/advanced imaging services. You have been asked to pay $100.76 which is less than your copayment amount of $125 for a CT scan. Since a CT scan was provided, the correct copayment has been applied. A CT scan falls within the outpatient diagnostic tests/network/advanced imaging services 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 a CT scan provided.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge day management services coded 99239 provided to the enrollee on April 27, 2019.
You asked the Plan to pay for the hospital discharge day management services. 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. In this case, the CPT Code Manual definition of code 99239 is Hospital discharge day management; more than 30 minutes. We find that CPT code 99239 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. A documented duration of time of 31 minutes or more is required to support this code. Based on this information, we decided that Medicare rules for coverage of the hospital discharge day management services have not been met. Therefore, we decided that the Plan does not have to pay for the hospital discharge day management services coded 99239 provided to the enrollee on April 27, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe 2 extractions, 2 guided tissue regenerations, 2 bone replacement grafts for ridge preservation, and maxillary interim partial denture provided on August 14, 2019.You asked the Plan to pay forthe extractions, guided tissue regenerations, bone replacement grafts, and maxillary interim partial denture. You say that you believe you were denied coverage because you went to an oral surgeon instead of your dentist for the services.The Plan denied your request. The Plan says the extractions were processed according to Connection Dental's (PPO USA) negotiated rate. The Plan also says that the guided tissue regenerations, bone replacement grafts, and maxillary interim partial denture are not covered services.Medicare generally does not cover dental services. However, the Planoffers 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 guided tissue regeneration, bone replacement graft, and maxillary interim partial denture are not among those covered under this benefit. The contract also clearly states that there is a 50% coinsurance for extractions when they are provided in-network. The Plan is only obligated to pay a 50% coinsurance when extractions are provided in-network. The record shows that you are only responsible for the 50% coinsurance for each extraction.Therefore, we decided that the Plan does not have to pay forthe 2 extractions, 2 guided tissue regenerations, 2 bone replacement grafts for ridge preservation, and maxillary interim partial denture provided on August 14, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care services (99291) provided on June 7, 2019 through June 8, 2019.
You asked the Plan to pay for the critical care services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted do not include a critical care progress note for the billed dates of service.
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 documentation submitted does not include a critical care progress note for June 7, 2019 through June 8, 2019. Based on this information, we decided that Medicare rules for coverage of the critical care services have not been met. Therefore, we decided that the Plan does not have to pay for critical care services (99291) provided on June 7, 2019 through June 8, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing services provided to on June 20, 2019.You asked the Plan to pay forthe drug testing services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met.Therefore, we decided that the Plan does not have to pay forthe drug testing services provided on June 20, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvefilling for teeth 27(D2330) and filling for tooth 28 (D2391) provided by "the doctor" on August 26, 2019.You asked the Plan to pre-approvethe fillings. You say that you should have a benefit amount of $1,000 notto exceed 6 surfaces according to chapter 4 page 63 of the annual notice of evidence of coverage for 2018.The Plan denied your request. The Plan says this benefit has been exhausted.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. The plan rules says members are allowed one restoration per tooth every 24 months. Per records you received this service on the same teeth on August 22, 2019.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-approvefilling for teeth 27 (D2330) and filling for tooth 28 (D2391) provided by "the doctor" on August 26, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on August 13, 2019 by out of network provider, "the provider".You asked the Plan to pay foroutpatient lab work. You say that it is the referring physician responsibility to obtain prior authorization.The Plan denied your request. The Plan says there was not prior authorization obtained for the service in question. The Plan says that the referring doctor 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 thePlan. 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 forthe medical services provided on August 13, 2019 by out of network provider, "the provider".
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe hospital discharge day management services provided on April 22, 2019.You asked the Plan to pay forthe hospital discharge day management services. 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.In this case, the CPT Code Manual definition of code 99239 is Hospital discharge day management; more than 30 minutes.We find that CPT code 99239 is not supported in the medical record. Specifically, the submitted discharge summary does not supporthospital discharge day management of more than 30 minutes was performed. A duration of 31 minutes or more is required to support this code. Based on this information, we decided that Medicare rules for coverage of the hospital discharge day management services have not been met.Therefore, we decided that the Plan does not have to pay forthe hospital discharge day management services provided on April 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services (CPT 98943, CPT 97110) provided to the enrollee on July 27, 2019.
You asked the Plan to pay for the chiropractic services. You say that the services were medically necessary. The Plan denied your request. The Plan says these are not covered services.
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 the chiropractic services (CPT 98943, CPT 97110) provided to the enrollee on July 27, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe subsequent nursing facility care (99308) provided May 27, 2019 to June 10, 2019 by an out of network provider.You asked the Plan to pay forthe subsequent nursing facility care. You say that the records provided should support the necessity of the services in dispute.The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. The plan says that non-emergent services with non-contracted providers require prior-authorization prior to services being rendered.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 forthe subsequent nursing facility care (99308) provided May 27, 2019 to June 10, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora wrist-hand orthosis (L3916) provided to the enrollee on April 29, 2019.You asked the Plan to pay for the orthosis. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The Plan follows Medicarerules. Medicare rules say that the documentation must support the items meet Medicare coverage criteria. 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 orthosis. Our reviewer says that the service is not medically necessary. 
Our physician reviewer found the documentation in the case file does not support that the requested wrist/hand orthosis was medically reasonable and necessary for the enrollee in this case. An appropriate history and a physical examination of the wrist would reasonably be required to adequately assess whether the wrist/hand orthosis was medically reasonable and necessary. The documentation does not support that the wrist/hand orthosis was medically reasonable and necessary in this case, as there is insufficient documentation of a physical examination of the wrist.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 orthosis have not been met.Therefore, we decided that the Plan does not have to pay fora wrist-hand orthosis (L3916) provided to the enrollee on April 29, 2019
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound provided on August 22, 2019.
You asked the Plan to waive the copayment for an ultrasound. You say that you disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are 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). Your contract with the Plan clearly says that you must pay a $250 copayment per day for diagnostic radiology services. You have been asked to pay the allowed amount of $101.16, which is less than the $250 copayment for an ultrasound. An ultrasound falls within the outpatient diagnostic tests and therapeutic services and 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 copayment for an ultrasound provided on August 22, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for primary service) (CPT Code 99292) provided to the enrollee on April 21, 2019.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the medical records do not support this service.
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 99292 is not supported in the medical record. Specifically, Current Procedural Terminology (CPT) code 99292 (3 units) remains not supported. This code represents an additional 30 minutes of critical care time in addition to the first 30-74 minutes of a critical care evaluation and management service ((Current Procedural Terminology (CPT) code 99291). The documentation submitted indicate that a total critical care time of 110 minutes was performed. Therefore, the billed service for an additional 90 minutes (1 unit = 30 minutes) is not supported. It is noted that multiple attempts were made to contact the provider for additional information. 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 critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for primary service) (CPT Code 99292) provided to the enrollee on April 21, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plandoes not haveto pay forthe home health services provided from May 16, 2019 to May 28, 2019.You asked the Planto pay forthe home health services. You say that this claim should be approved for payment.The Plandenied your request. The Plansayshome health claims must include a Q-code on the date of the first visit to correspond to the location in which the services were provided. Since this is not present, the claim is not payable.The Plan must follow Medicare rules. Medicare rules say that Q-codes describing the location in which the home health care is rendered must be included on the claim.In this case, the claim does not listany of the three Q-codes required for home health billing.Therefore, we decided that the Plandoes not haveto pay forthe home health services provided from May 16, 2019 to May 28, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fordiabetic testing supplies (E2100, A4253, A4259, A4256) provided June 28, 2019 to September 16, 2019 by the provider.You asked the Plan to pay forthe diabetic supplies. You say that the items were medically necessary.The Plandenied your request. The Plan says the claim did not include 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 physician order and 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. There was no order or tracking number provided.Therefore, we decided that the Plan does not have to pay fordiabetic testing supplies (E2100, A4253, A4259, A4256) provided June 28, 2019 to September 16, 2019.