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

We decided that the Plan does not have to waive the deductible and copayment forambulance services provided on August 27, 2019.You asked the Plan to waive the deductible and copayment forambulance services. You say that you disagree with the high 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. Your contract with the Plan says that there is a $750 deductible. Your contract with the Plan also clearly says that after the $750 deductible has been met, enrollee's must pay a $100 copayment for ambulance services.You received ambulance services on August 27, 2019. The record shows that you had only paid $367.62 toward the $750 deductible. Therefore, you are responsible to pay the remaining balance of $382.38. Now that the $750 deductible has been met, you are also responsible to pay $51.52, which is less than the $100 copayment. The total amount you owe is: $433.90.The item or service you asked the Plan to waive the deductible and copayment for falls within the benefit category ambulance services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible for ambulance services. This cost sharing is a contractual obligation that had not been met at the time ambulance services was received on August 27, 2019.Therefore, we decided that the Plan does not have to waive the deductible and copayment forambulance services provided on August 27, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the diabetic supplies provided to the enrollee from August 2, 2019 to October 21, 2019.
You asked the Plan to pay for the diabetic supplies. The Plan denied your request. The Plan says that valid proof of delivery was not submitted.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The tracking ticket does not include the items supplied and the delivery ticket does not include a tracking number to confirm it was delivered. Therefore, we decided that the Plan does not have to pay for the diabetic supplies provided to the enrollee from August 2, 2019 to October 21, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis coded L0650 provided on May 23,
2019.
You asked the Plan to pay for the lumbar-sacral orthosis. 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 L0650 is Lumbar-sacral orthosis, sagittal-coronal control,
with rigid anterior and posterior frame/panel(s), posterior extends from sacrococcygeal junction to t-9 vertebra,
lateral strength provided by rigid lateral frame/panel(s), produces intracavitary pressure to reduce load on
intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen
design, prefabricated, off-the-shelf.
We find that CPT code L0650 is not supported in the medical record. Specifically, the documentation does not
indicate that a lumbar-sacral orthosis was dispensed or fitted on the billed date of service. Based on this
information, we decided that Medicare rules for coverage of the lumbar-sacral orthosis have not been met.
Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis coded L0650 provided
on May 23, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe cystourethroscopy services provided on August 7, 2019.You asked the Plan to pay forthe cystourethroscopy services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan saysthe 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 CodeManual definition of code 52442 is Cystourethroscopy, with insertion of permanent adjustable transprostatic implant; each additional permanent adjustable transprostatic implant (List separately in addition to code for primary procedure).We find that five units of CPT code 52442 are not supported in the medical record. Specifically, the medical records did not include documentation of a cystourethroscopy with insertion of permanent adjustable transprostatic implant; each additional permanent adjustable transprostatic implant for five units. In this case, the procedure was documented however the request units do not appear to be correct a total of 5 units were described, with code 52441 approved for one unit, only 4 additional successful implants were described. As a result, the requested procedure code is not substantiated by the clinical documentation in the operative report submitted for review. Based on this information, we decided that Medicare rules for coverage of the cystourethroscopy services have not been met.Therefore, we decided that the Plan does not have to pay forthe cystourethroscopy services provided on August 7, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the portable oxygen concentrator purchased on June 18, 2019.
You asked the Plan to reimburse you for the portable oxygen concentrator system. You say that a portable oxygen concentrator makes travel to appointments safer, easier, and quicker. The Plan denied your request. The Plan says purchased oxygen equipment is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. Medicare rules say that only rented oxygen equipment is eligible for coverage. We looked at the file and Medicare rules. Purchased oxygen equipment is statutorily non-covered by Medicare. Based on this information, we decided that Medicare rules for coverage of the portable oxygen concentrator system have not been met. Therefore, we decided that the Plan does not have to reimburse you for the portable oxygen concentrator purchased on June 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foran office visit provided on June 24, 2019 by out of network provider.You asked the Plan to pay foran office visit. You say that you were never told that the doctor's office did not take your specific plan. You say that they admitted it was their mistake but now you are stuck with the bill.The Plan denied your request. The Plan says the member was self-referred. The Plan says that there are in-network providers available.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 foran office visit provided on June 24, 2019 by out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient lab work provided on August 5, 2019 by an out of network provider.
You asked the Plan to pay for outpatient lab work. You say that your doctor referred you. You say that they are in the same building as your provider. The Plan denied your request. The Plan says the referring doctor is out-of-network. The Plan says that 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. Evidence shows that you have an HMO plan, not a PPO plan; therefore, payment has been correctly denied. Therefore, we decided that the Plan does not have to pay for outpatient lab work provided on August 5, 2019 by the out of network provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided from June 1, 2019 to July 13, 2019.
You asked the Plan to pay for the 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 received are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare pays for services only when they are furnished by a provider or supplier enrolled in the Medicare program. Review of the file shows that this practice was not Medicare-certified during the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the home health services provided from June 1, 2019 to July 13, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plandoes not have to pre-approve skilled nursing facility (SNF) care.You asked the Planto pre-approveSNF care. You say that the services are necessary.The Plandenied your request. The Plansays based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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-approveSNF care. Our reviewer says that the services are not medically necessary. Our physician reviewer found based on available records, you do not meet criteria for coverage of SNF. The records do not support that you need daily physical therapy (PT) and occupational therapy (OT). There are no noted daily skilled complex nursing needs. You are ambulating household distances and require little assistance with mobility and transfers. While you may benefit from continuing PT and OT, the records do not support the need for daily therapy.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF carehave not been met.Therefore, we decided that the Plandoes not have to pre-approveskilled nursing facility (SNF) care
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the train of four testing services provided to the enrollee on
May 13, 2019.
You asked the Plan to pay for the train of four testing. The Plan denied your request. The Plan says the
documentation does not support that the billed code was performed.
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. Train of Four Testing does not fit the
criteria set by CMS and Insurance Carriers for CPT 95937. There is no separate code for Train of Four
Monitoring, therefore, it would be inappropriate to bill the Neuromuscular Junction Testing code for Train of
Four Monitoring. Based on this information, we decided that Medicare rules for coverage of the train of four
testing have not been met. Therefore, we decided that the Plan does not have to pay for the train of four testing
services provided to the enrollee on May 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on October 4, 2019 by out of network provider. You asked the Plan to pay foran office visit. You say that you were told that the doctor took your insurance.The Plan denied your request. The Plan says no prior authorization was obtained for these services.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay foran office visit provided on October 4, 2019 by out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lens, frames and miscellaneous vision services provided on September 3, 2019.You asked the Plan to pay forthese services. You say that you were not aware you had to wait exactly two years.The Plan denied your request. The Plan says that you had reached you routine vision allowance.Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a routine eye exam and up to $100 for routine eyewear every two years.We looked at the file and the Plan's rules. The file shows that the plan has approved the maximum benefit of $100 for routine eyewear. There is no provision in the contract which would require the plan to approve more than this amount for the routine eyewear.The miscellaneous vision service is not covered by the plan. Therefore, we decided that the Plan does not have to pay forthe lens, frames and miscellaneous vision services provided on September 3, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory testing provided on August 2, 2019.You asked the Plan to pay forthe laboratory testing. 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.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy provided on August 15, 2019.
You asked the Plan to waive the copayment for the colonoscopy. You say that your benefits book says preventive screenings are covered. You say that you are appealing the rejection of the copayment. The Plan denied your request. The Plan says the copayment 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 $300 copayment for each Medicare covered surgical procedure in an outpatient hospital facility. You have been asked to pay a $300 copayment for the colonoscopy. The colonoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show that the colonoscopy was ordered for diagnostic purposes. 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 colonoscopy provided on August 15, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiation services (77523, G6002, 77336) provided on July 5, 2019.
You asked the Plan to pay for the radiation services. You say that the services were medically necessary. The Plan denied your request. The Plan says services performed as part of a clinical trial must be billed to original Medicare.
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in Original Medicare and the plan cost-sharing for the same services. In this case, you asked the Plan to pay for the radiation services as part of a clinical trial. The Plan does not cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pay for radiation services (77523, G6002, 77336) provided on July 5, 2019.
Appeal type: ER
Decision: Partially Favorable

We decided that the Plan has to pay forCPT 93010. We decided that the Plan does not have to pay forCPT 99285. You asked the Plan to pay forthe services. You say that this should be paid for.The Plan says that the denied codes are not supported.We decided that the Planhas to pay forCPT 93010.The Plan follows 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 CPT 93010 is "Electrocardiogram, routine ECG with at least 12 leads."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 for CPT 93010. Our reviewer says that CPT code 93010 is supported by the medical record. Our coding reviewer found that the record contains the professional interpretation and report of the ECG performed during this episode of care. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CPT 93010 have been met.Therefore, we decided that the Plan has to pay forCPT 93010. We also decided that the Plandoes not have to pay forCPT 99285.
The Plan follows 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 CPT 99285 is "Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high severity and pose an immediate significant threat to life or physiologic function."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 for CPT 99285. Our reviewer says that [CPT code 99285 is not supported by the medical record. Our physician reviewer found that the documentation does not support that the E&M provided in the emergency department consisted of a comprehensive history, a comprehensive examination, and medical decision making of high complexity. According to coding rules, there is a more specific code for the level of care provided. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CPT 99285 have not been met.Therefore, we decided that the Plan does not have to pay forCPT 99285.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 the LTACH services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital (ACH) having been admitted with a gangrenous foot. The enrollee received a transmetatarsal amputation and subsequently underwent drainage of a perianal abscess. The enrollee is receiving antibiotics and wound care. The enrollee is not intubated/ventilated. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.