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

We decided that the Plan does not have to pay for the genetic testing rendered on January 14, 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 testing is not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.
The testing at issue in this appeal was requested solely for screening purposes. There is no documentation to
support that the testing was performed for a Medicare-covered indication. Medicare does not cover this testing
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the genetic testing
rendered on January 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the urology supplies.You asked the Plan to pay for the urology supplies. You say that this claim should be paid.The Plan denied your request. The Plan says this claim cannot be paid separately based on Medicare guidelines for inpatient services.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF to be a home. Records show that the urology supplies were used in a SNF. Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary.Therefore, we decided that the Plan does not have to pay for the urology supplies.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on
January 8, 2019.
You asked the Plan to waive the copayment for the emergency room visit. You say that you do not agree with
the copayment because refuse to pay the hospital $100. 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 $100
copayment for each Medicare-covered visit to a hospital emergency room inside or outside the United States.
You have been asked to pay a $100 copayment for the emergency room visit. The emergency room visit falls
within the "Emergency care" 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
emergency room visit provided on January 8, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomographic (CT) angiography of the abdomen and pelvis (74174).
You asked the Plan to pre-approve a CT angiography of the abdomen and pelvis. You say that the service is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 angiography of the abdomen and pelvis. Our reviewer says that the service is not medically necessary. Our physician reviewer found the records do not indicate that a CT angiography of the abdomen and pelvis is medically reasonable and 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 angiography of the abdomen and pelvis have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomographic (CT) angiography of the abdomen and pelvis (74174).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the assistant surgeon services provided on November 6, 2019.
You asked the Plan to pay for the assistant surgeon services. You say that you would lie the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS. In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for the assistant surgeon services provided on November 6, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy rendered from January 22, 2020 to January 28, 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 covered.
The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies. We looked at the file and Medicare and the Plan's rules. Based on this information, we decided that Medicare and the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy rendered from January 22, 2020 to January 28, 2020.
Benefits for these services 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit received on February 6, 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 provider is not participating in the plan's 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 rendering 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 received on February 6, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered from April 20, 2019 to June 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 the claim was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that home health claims must be billed with one of three required Q codes. We looked at the file and Medicare rules. The claims were not billed with a required Q code. 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 home health services rendered from April 20, 2019 to June 14, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a manual wheelchair (K0001).You asked the Plan to pre-approve the wheelchair. You say that the wheelchair is medically necessary.The Plan denied your request. The Plan says rules for coverage have not been met.The Plan follows Medicare rules. Medicare rules say that wheelchairs are covered when medically necessary, when the enrollee's condition cannot be aided with a cane or walker, and when the wheelchair can be used safely in the home.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 wheelchair. Our reviewer says that the wheelchair is not medically necessary. Our physician reviewer found documentation does not support that the coverage criteria for a manual wheelchair have been met in this case. The documentation does not support that the enrollee has a mobility limitation that significantly impairs her ability to participate in one or more mobility-related activities of daily living, and that the her mobility limitation cannot be sufficiently resolved by the use of an appropriately fitted cane or walker, and that the home provides adequate access between rooms, maneuvering space, and surfaces for use of the manual wheelchair that is provided.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 wheelchair have not been met.Therefore, we decided that the Plan does not have to pre-approve a manual wheelchair (K0001).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit rendered on October 15, 2019. You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 99204 is not supported. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99204 is new patient office or other outpatient visit, typically 45 minutes. We find that CPT code 99204 is not supported in the medical record. Specifically, the file shows that the enrollee received office visit services from a provider within the same physician group practice within the past three years; therefore, a new patient office visit does not apply. 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 office visit rendered on October 15, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a segmental pneumatic appliance for use with pneumatic compressor, full leg (E0667) and pneumatic compressor, segmental home model with calibrated gradient pressure (E0652).
You asked the Plan to pre-approve a segmental pneumatic appliance for use with pneumatic compressor, full leg and pneumatic compressor. You say that the items are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that pneumatic compression devices are covered when specific criteria is met. 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 segmental pneumatic appliance for use with pneumatic compressor, full leg and pneumatic compressor. Our reviewer says that the items are not medically necessary. Our physician reviewer found the records do not indicate evidence of proximal lymphedema, or indication that a standard pneumatic compression device can address ongoing needs. As such, this request is not in line with policy and is not 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 segmental pneumatic appliance for use with pneumatic compressor, full leg and pneumatic compressor have not been met. Therefore, we decided that the Plan does not have to pre-approve a segmental pneumatic appliance for use with pneumatic compressor, full leg (E0667) and pneumatic compressor, segmental home model with calibrated gradient pressure (E0652).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids (V5254) purchased December 3, 2019. You asked the Plan to pay for the hearing aids. You say that there are no in-network providers in the enrollee's area. The services rendered were convenient and accessible. The Plan denied your request. The Plan says Hearing aids ordered through providers other than certain practices are not covered. Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when ordered through this practice. Hearing aids ordered through providers other than these are not covered. We looked the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids (V5254) purchased December 3, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0483 provided on November 13, 2018.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 code G0483 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting place of service 11. 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 G0483 provided on November 13, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the upper GI endoscopy and the Part B injections provided on January 28, 2020. You asked the Plan to waive the cost share for the upper GI endoscopy and the Part B injections. You say that you should have never been billed and that you should not have a balance of $201.46. 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 $200 copayment per in-network visit and 20% coinsurance for each in-network Medicare-covered Part B drug. You have been asked to pay a $200 copayment for the upper GI endoscopy. You have also been asked to pay $1.46 which is 20% of the allowed amount for the Part B injections. The allowed amount is $7.30. ($7.30 x 20% = $1.46). ($200 + $1.46 = $201.46). The upper GI endoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The Part B injections fall within the "Medicare Part B prescription drugs" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the cost share for the upper GI endoscopy and the Part B injections provided on January 28, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the open treatment of femoral shaft fracture with plate/screw services coded 27507 provided on April 29, 2019.You asked the Plan to pay for the open treatment of femoral shaft fracture with plate/screw 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 27507 is open treatment of femoral shaft fracture with plate/screws, with or without cerclage.We find that CPT code 27507 is not supported in the medical record. Specifically, the operative report did not include documentation of an open treatment of femoral shaft fracture with plate/screws, with or without cerclage, therefore, this code cannot be verified. Based on this information, we decided that Medicare rules for coverage of the open treatment of femoral shaft fracture with plate/screw services have not been met.Therefore, we decided that the Plan does not have to pay for the open treatment of femoral shaft fracture with plate/screw services coded 27507 provided on April 29, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on June 6, 2019 by an out of network (OON) provider. 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 were rendered by an out-of-network provider without 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 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 laboratory services provided on June 6, 2019 by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services provided from October 24, 2019 to February 21, 2020 by an out of network (OON) provider.
You asked the Plan to pay for these OON services. You say that you would like the plan to reconsider their denial The Plan denied your request. The Plan says the services provided 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 physical therapy services provided from October 24, 2019 to February 21, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC) with multiple power options.You asked the Plan to pre-approve these services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that a Group 3 PWC is covered when specific criteria are met.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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has left-sided hemiplegia after a stroke. Comorbid conditions include chronic obstructive pulmonary disease (COPD). The records do not support that a lesser device could not safely and adequately address the enrollee's needs; therefore, the Group 3 PWC is not reasonable or 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC) with multiple power options.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on February 19, 2020.
You asked the Plan to pay for the laboratory services. 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 laboratory services provided on February 19, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four testing (95999) provided on October 22, 2019.
You asked the Plan to pay for train of four testing. You say that this was medically necessary. The Plan denied your request. The Plan says payment of this service is bundled into other services.
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 95999 is not supported in the medical record. Specifically, the use of unlisted CPT code 95999 to report train of four testing is not supported. According to CPT coding rules, train of four testing is not a separately reportable procedure and is included in the other intraoperative neuromonitoring procedures. Based on this information, we decided that Medicare rules for coverage of train of four testing have not been met. Therefore, we decided that the Plan does not have to pay for train of four testing (95999) provided on October 22, 2019.