Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Inpatient Services provided June 12, 2019 to June 15, 2019.
You asked the Plan to waive the copayment for the inpatient services. You say that you were told this would be a clinic visit and you would not be charged. The Plan denied your request. The Plan says the correct copayment was 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 $360 per day copayment for Inpatient Hospital Services. You have been asked to pay a $360 per day copayment for the inpatient services. The inpatient services fall within the Inpatient Hospital 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 Inpatient Services provided June 12, 2019 to June 15, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for test strips, lancets, control solution, and batteries provided from August 4, 2019 to October 23, 2019.You asked the Plan to pay for test strips (A4253), lancets (A4259), control solution (A4256), and batteries (A4235). You say that The Plan should pay this claim.The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.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 Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered.Therefore, we decided that the Plan does not have to pay fortest strips, lancets, control solution, and batteries provided from August 4, 2019 to October 23, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the root removal, bone replacement grafts, tissue regeneration and oral surgery provided on July 31, 2019.You asked the Plan to pay for the root removal, bone replacement grafts, tissue regeneration and oral surgery. You say that it was your understanding that all dental work was covered. You say that you cannot afford the large amount you are being charged.The Plan denied your request. The Plan says these are not covered benefits.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.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 pay for the root removal, bone replacement grafts, tissue regeneration and oral surgery provided on July 31, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services.You asked the Plan to pay forthe ambulance services. You say that during the night your blood sugar dropped extremely low. Anambulance was called and the responders came and treated you. You say that you could have died if 9-11 wasn't called and an ambulance sent.The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on July 8, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay forthe ambulance services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay fordrug testing services provided to"the provider" on July 3, 2019.You asked the Plan to pay forthe services. You say that this should be paid for.The Plan denied your request. The Plan says there is a more appropriate code to use.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 definition of HCPCS code G0483 is "Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to, GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21 drug class(es), including metabolite(s) if performed."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 services. Our reviewer says that the services at issue in this case were not coded correctly. Our physician reviewer found the documentation submitted did not include a physician order/lab requisition for definitive/confirmative drug test(s), 15-21 or more drug classes. Of note, there is a more appropriate Healthcare Common Procedure Coding System (HCPCS) code, G0481, which includes specimen validity testing, per day; 8-14 drug class(es), including metabolite(s) if performed. Therefore the billed code cannot be verified. The review has determined that the records do not support the coding of HCPCS G0483.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 services have not been met.Therefore, we decided that the Plan does not have to pay fordrug testing services provided to "the provider" on July 3, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that the Plan should cover the services. You say that you passed out because your blood sugar was low and that the paramedic response and treatment was medically necessary. You decided not to go the hospital because you were feeling better after treatment. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on February 1, 2019 by an out of network provider. You asked the Plan to pay for the practitioner services. You say that the provider is in network with the Plan. You say that the provider has been in network since November 30, 2019. The Plan denied your request. The Plan says the provider was not contracted with the Plan on the date of service. The Plan says the enrollee self-directed for the services. The Plan also says the services were not urgent or emergent. 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 provided on February 1, 2019 by an out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

e decided that the Plan does not have to pay forvacuum drainagecollection unit and tubing kit (A7048) provided by "the provider", on June 25, 2019.You asked the Plan to pay forvacuum drainage collection unit and tubing kit. You say that the records provided should support the necessity of theservices in dispute.The Plan denied your request. The Plan says the records do not support the service billed.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 itemized shipping/billing invoice for the items at issue in this appeal. The record does not contain a valid itemized shipping/billing invoice for the supplies provided in this case.Therefore, we decided that the Plan does not have to pay for vacuum drainage collection unit and tubing kit (A7048) provided by "the provider", on June 25, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on July 1, 2019.You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order/lab requisition.The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. 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 for the drug testing services provided on July 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services (CPT 99153) provided to the beneficiary on August 30, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the Medicare rule for payment of this claim has not been met.The Plan must follow Medicare rules. Medicare rules say that the OPPS recognizes that CPT code 99153 is a practice expense (PE) only code andis not paid in the facility setting. The Outpatient Prospective Payment System (OPPS) applies to all hospital outpatient departments.We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment for CPT code 99153 under the OPPS when performed in the facility setting.Therefore, we decided that the Plan does not have to pay forthe services (CPT 99153) provided tothe beneficiary on August 30, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe anesthesia services rendered on May 30, 2018.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 claim has not been processed by the primary insurer.The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer.The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan confirmed on October 2, 2019 that it was the primary insurer effective January 1, 2018 to September 28, 2018. The Plan has not received an Explanation of Benefits from the primary insurer for this claim. As the secondary insurer, the Plan cannot be held responsible for these services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay forthe anesthesia services rendered on May 30, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for 30 minutes of advanced care planning provided on April 4, 2019. You asked the Plan to pay for the advanced care planning. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted did not include documentation of advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate; therefore, the billed service cannot be verified. 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 99497 is advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate We find that CPT code 99497 is not supported in the record. Specifically, the record does not indicate that 30 minutes of advance care planning was rendered. Based on this information, we decided that Medicare rules for coverage of the advanced care planning have not been met. Therefore, we decided that the Plan does not have to pay for 30 minutes of advanced care planning provided on April 4, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered to the enrollee on August 13, 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 enrollee was on hospice.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay for the services rendered to the enrollee on August 13, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for bilateral knee orthoses with suspension sleeves (L1833, L2397) provided to the enrollee on August 20, 2019.
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your request. The Plan says the enrollee has previously received the same supplies within the 5-year RUL.
The plan must follow Medicare rules. Medicare rules say that the reasonable useful lifetime of durable medical equipment is no less than five years. Replacement equipment may be granted when irreparable wear or irreparable damage is demonstrated or there has been a change in the enrollee's medical condition. We looked at the file and Medicare rules. In this instance, the submitted documentation indicates that the enrollee has received the same durable medical equipment on April 5, 2018 and September 27, 2018. These orthoses are still within the 5-year RUL and the documentation submitted does not show that the orthoses are
irreparably worn, irreparably damaged, or that the enrollee had a change in medical condition to warrant the orthoses at issue. 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 knee orthoses with suspension sleeves (L1833, L2397) provided to the enrollee on August 20, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on July 8, 2019 and billed under code G0483.You asked the Plan to pay for this service. You say that this claim should be paid.The Plan denied your request. The Plan says based on the records provided, Medicare coverage criteria for coverage of code G0483 was not met.The Plan must follow Medicare rules. Medicare has specific documentation requirements for this type of testing. The physicians order and the medical records must specifically show how this testing will be used to treat illness or disease present in the enrollee at the time of service as opposed to this testing being done for screening purposes. Based on the records provided, the required Medicare criteria are not met. Therefore, we decided that the Plan does not have to pay for drug testing provided to the enrollee and billed under code G0483.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation, prophylaxis, and bitewings provided by the doctor, on April 11, 2019.
You asked the Plan to pay for the periodic oral evaluation, prophylaxis, and bitewings. You say that prior to the appointment you spoke with the Plan and they gave you permission to be treated by this facility. The Plan denied your request. The Plan says the doctor, is an out-of-network provider. The Plan also says the record shows that you did contact the Plan but no providers were discussed and the Plan did not advise you that any exception would be made for you to be treated by an out-of-network provider.
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. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered when the services are received out-of-network. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation, prophylaxis, and bitewings provided by the doctor, on April 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (Q9967, 94727, 94010) provided to the enrollee on April 17, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services cannot be verified.
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 Q9967 is "Low osmolar contrast material, 300-399 mg/ml iodine concentration, per ml". The CPT Code Manual definition of code 94727 is "Gas dilution or washout for determination of lung volumes and, when performed, distribution of ventilation and closing volumes". The CPT Code Manual definition of code 94010 is "Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement(s), with or without maximal voluntary ventilation". We asked our coding reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the use of code Q9967 is not supported by the records provided. Our coding reviewer found that the medical record does not contain the iodine concentration of the contrast that was used. It cannot be verified that 300-399 mg/ml is the correct concentration. CPT codes 94727 and 94010 are also not supported by the medical record. The documentation does not contain evidence that these procedures were 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 the services have not been met. Therefore, we decided that the Plan does not have to pay for the services (Q9967, 94727, 94010) provided to the enrollee on April 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for acupuncture treatment provided to the enrollee from May 20, 2019 to June 14,2019.You asked the Plan to pay for these services. You say that these services should be covered by the Plan.The Plan denied your request. The Plan says the enrollee exhausted the acupuncture visits prior to the dates of service in question.The rules say that acupuncture services are not covered by Medicare. However, the Plan offers an acupuncture benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers 20 acupuncture visits per year.That benefit was exhausted prior to the dates of service in question. Therefore, we decided that the Plan does not have to pay for acupuncture treatment provided to the enrollee from May 20, 2019 to June 14, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lab services provided to the enrollee on July 5, 2019 by "the provider". You asked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network 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 forthe lab services provided to the enrollee on July 5, 2019.