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

We decided that the Plan does not have to pay for services provided to the enrollee, by a chiropractor.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says physical therapy modalities, x-rays, rehab, and other incidental services by chiropractors are not covered by Medicare.
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 file shows that the enrollee received mechanical traction therapy, manual therapy, and electrical stimulation. The services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for services provided to the enrollee, by a chiropractor.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for nursing facility care (99309) provided on August 23, 2019.You asked the Plan to pay for nursing facility care. You say that this claim should be reprocessed and paid.The Plan denied your request. The Plan says payment of this claim is the responsibility of Original Medicare.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 nursing facility care (99309) provided on August 23, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay forhospital care (99232) provided on August 26, 2019 and August 27, 2019.You asked the Plan to pay forhospitalcare. You say that the enrollee was not enrolled in hospice on these dates of service.The Plan denied your request. The Plan says payment of these services is the responsibility of Original Medicare.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on August 18, 2019. The services in question were provided before the end of that month.Therefore, we decided that the Plan does not have to pay forhospital care (99232) provided on August 26, 2019 and August 27, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on May 6, 2019.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 records do not support the service billed.The Plan must follow Medicare rules. Medicare rules say that a physician order must be present for labs to be covered.The documentation submitted did not include a physician order/lab requisition or medical records stating exactly tests were to be performed. 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 laboratory services provided on May 6, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on August 16, 2019 by out-of-network provider. You asked the Plan to pay for the out-of-network services. You say that the services were medically reasonable and necessary.The Plan denied your request. The Plan says there is no network deficiency for the services, and alternate network providers were found.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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these out-of-network services.Therefore, we decided that the Plan does not have to pay for the lab services provided on August 16, 2019 by out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided on April 15, 2019.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 Current Procedural Terminology (CPT) code 88305 (16 Units) remains 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.We find that CPT code 88305 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's office (POS 11). 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 lab services provided on April 15, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forthe Albuterol inhaler provided on August 8, 2019.You asked the Plan to pay forthe Albuterol inhaler. You say that this drug wasan important part of your improvement.The Plan denied your request. The Plan says that this is not a Part B covered drug.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. Theself-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pay forthe Albuterol inhaler provided on August 8, 2019.Benefits for the Albuterol inhalermay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the glucose monitor, test strips, lancets, control solution, and
lancet device provided by the supplier.
You asked the Plan to pay for the glucose monitor (E0607), test strips (A4253), lancets (A4259), control
solution (A4256), and lancet device (A4258). 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 for the glucose
monitor, test strips, lancets, control solution, and lancet device provided by the supplier.
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 by the supplier.
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 for test strips,
lancets, control solution, and batteries provided by the supplier.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay forthe acute inpatient hospital care provided on February 7, 2019 through February 11, 2019.You asked the Plan to pay for acute inpatient hospital care. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that the member could have returned to the Sub-Acute Nursing Facility of Residence for continued antibiotic therapy hydration and observation.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the record shows that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights. The severity of the presenting symptoms supported this expectation and medically necessary care did span more than two midnights.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided on February 7, 2019 through February 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on July 26, 2019 by an out of network 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 forthe medical services provided on July 26, 2019 by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forout of area (out of state) services provided on July 25, 2019.You asked the Plan to pay forthis service. You say that you were told this service would be covered.The Plan denied your request. The Plan says you did nottransfer your benefits out of state prior to receiving the service.Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care.  Based on the records provided, this service could have been provided in network and was not authorized out of network by the plan. Therefore, we decided that the Plan does not have to pay forout of area (out of state) services provided on July 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the glucose monitor, test strips, lancets, control solution, and lancet device provided from May 15, 2019 to August 3, 2019.
You asked the Plan to pay for the glucose monitor (E0607), test strips (A4253), lancets (A4259), control solution (A4256), and lancet device (A4258). 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 for the glucose monitor, test strips, lancets, control solution, and lancet device provided from May 15, 2019 to August 3, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the DME provided to the enrollee on June 23, 2019.
You asked the Plan to pay for the DME. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says no authorization on file that matches services billed.
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. No authorization on file that matches services billed. Therefore, we decided that the Plan does not have to pay for the DME provided to the enrollee on June 23, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered to the enrollee on July 23, 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 with an appropriate place of service code.The Plan must follow Medicare rules. The rules say that CMS does not pay for an "inpatient-only" service furnished to a person who is registered in the hospital as an outpatient and reports the service on the outpatient hospital bill type (TOB 13X).We looked at the file and Medicare rules. The file shows that code 27197 (closed treatment of fracture and/or dislocation of pelvis and/or sacrum) was billed with place of service code 11 for an office. This code is on the inpatient-only list and cannot be paid in the outpatient setting.Therefore, we decided that the Plan does not have to pay for the surgical services rendered on July 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the skin repair surgery provided on August 5, 2019.
You asked the Plan to waive the copayment for the skin repair surgery. You say that you should not be responsible for the copayment. 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 $250 copayment per day for outpatient procedures and services, including but not limited to diagnostic and therapeutic endoscopy, and outpatient surgery performed in an outpatient hospital or ambulatory surgical center. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $250 copayment for the skin repair surgery.
You have been asked to pay a $190.44 copayment for the skin repair surgery. The skin repair surgery falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 skin repair surgery provided on August 5, 2019.
Your complaint that the staff did not do a good job on the wound is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on April 30, 2019 by out of network provider. You asked the Plan to pay for physical therapy. You say that you are in-network with the Plan. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and the referring physician is also out-of-network with the Plan. 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 medical services provided on April 30, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the power wheelchair provided on August 15, 2019.
You asked the Plan to pay for the power wheelchair. You say that this is medically necessary. The Plan denied your request. The Plan says that there is no documentation stating your need for a power wheelchair.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The file shows does not show that you have a mobility deficit that impairs your participation in MRADLs, that your condition cannot be improved by a walker, cane or manual wheelchair or that you can safely operate the PMD. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pay for the power wheelchair provided on August 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for specialist services provided on August 7, 2019.You asked the Plan to pay for the services. You say that this was medically necessary.The Plan denied your request. The Plan says this provider is not in-network and does not work with the plan.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 specialist services provided on August 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care rendered to the enrollee by the 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 payment is included in the global surgical package.
The Plan must follow Medicare rules. The rules state that follow-up visits during the postoperative period of the surgery that are related to recovery from the surgery are included in the global surgical period. The provider submitted a claim for procedure code 99231 (subsequent hospital care) after surgical procedures billed with codes 28005 (treatment of foot bone lesion) and 13160 (late closure of wound). These codes have a 90-day global surgical period. Code 99231 was billed within the 90-day global period and payment is included in the global surgical package. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care rendered to enrollee by the provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy (45378) provided.
You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that you should not be responsible for the copayment since the colonoscopy should not have been billed as a diagnostic procedure. The Plan denied your request. The Plan says based on Medicare billing criteria, the claim was billed 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 when performed at a freestanding Ambulatory Surgical Center for same day outpatient surgery. You have been asked to pay $300 for the diagnostic colonoscopy. A diagnostic colonoscopy falls within the same day outpatient surgery 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 diagnostic colonoscopy (45378) provided.