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

We decided that the Plan does not have to waive the copayment for laboratory tests provided on September 20, 2019.
You asked the Plan to waive the copayment for laboratory tests. You say that the blood work was done in relation to a wellness visit. You say that the blood work should be included with the wellness visit. 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 $5 for Medicare-covered laboratory tests. You have been asked to pay a $5 copayment for laboratory tests. Laboratory tests fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. Outpatient diagnostic tests are considered a separate service. 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 laboratory tests provided on September 20, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the wrist hand orthosis provided on January 28, 2020.
You asked the Plan to pay for the wrist hand orthosis (L3916). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the documentation submitted did not indicate the provider discussed the need for the billed supply codes, therefore the billed supply codes cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. No medical records were received to support the diagnosis on the submitted order, therefore the billed codes cannot be supported. Based on this information, we decided that Medicare rules for coverage of the wrist hand orthosis (L3916) have not been met. Therefore, we decided that the Plan does not have to pay for the wrist hand orthosis provided on January 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis and suspension sleeve provided on January 13, 2020.
You asked the Plan to pay for the knee orthosis (L1833) and suspension sleeve (L2397). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the documentation submitted did not indicate the provider discussed the need for the billed supply codes, therefore the billed supply codes cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. The records do not contain a recent face-to-face encounter supporting that the enrollee was evaluated or treated for a condition that supports the orthoses. Based on this information, we decided that Medicare rules for coverage of the knee orthosis (L1833) and suspension sleeve (L2397) have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis and suspension sleeve provided on January 13, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for services provided between 10:00 PM and 8:00 AM at 24-hour facility (CPT 99053) provided on November 1, 2019.
You asked the Plan to pay for CPT code 99053. You say that the records provided support the CPT code in dispute. The Plan denied your request. The Plan says the service you are requesting coverage for is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that payment for codes with a status indicator of B is always bundled into payment for other services not specified. We looked at the file and Medicare rules. CPT code 99053 has a status indicator of B and is not paid for separately. Therefore, we decided that the Plan does not have to pay for services provided between 10:00 PM and 8:00 AM at 24-hour facility (CPT 99053) provided on November 1, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on November 6, 2019.You asked the Plan to pay for the ambulance transport to and from a doctor's office. You say that the facility staff called for the transport to the doctor appointment.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 pays for ambulance transports only when they meet certain origin and destination requirements. A doctor's office is not a covered destination. If the beneficiary is a resident of a SNF and must be transported by ambulance to receive dialysis or certain other high-end outpatient hospital services, the ambulance transport may be separately payable under Part B.Because the service is covered and payable as a beneficiary transportation service under Part A, the service cannot be classified and paid for as an ambulance service under Part B. You can find this in the Medicare Claims Manual Chapter 15 -Ambulance Transport.The services you have asked the Plan to pay for are ambulance transport services to a doctor's office.Therefore, we decided that the Plan does not have to pay for the ambulance services provided on November 6, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the four 2D oral/facial photographic images and oral hygiene instructions provided on January 13, 2020.
You asked the Plan to pay for the 2D oral/facial photographic images and oral hygiene instructions. You say that at the time you scheduled this appointment you provided your insurance information and were told that your insurance plan was accepted. You also say that you were not informed that this provider was not in-network with your plan. The Plan denied your request. The Plan says these services 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 four 2D oral/facial photographic images and oral hygiene instructions provided on January 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for home electrical repairs (A9270x3) provided September 27, 2019 to October 21, 2019. You asked the Plan to pay for the home electrical repairs. You say that you have purchased the lowest estimated standby generator already. You are trying to avoid having to go to a hotel during power outages.The Plan denied your request. The Plan says this service is not a covered  benefit.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plan does not have to pay for home electrical repairs (A9270x3) provided September 27, 2019 to October 21, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four testing (95999) provided on September 12, 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 interoperative 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 September 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an outpatient visit provided on January 13, 2020 by an out of network (OON) provider.You asked the Plan to pay for an outpatient visit. You say that you are not paying this. You say that they entered your insurance information and it cleared in the computer.The Plan denied your request. The Plan says no prior authorization was obtained. The plan says that these services were not referred by the member's primary care physician.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 an outpatient visit provided on January 13, 2020 by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the Emergency Room Services (99284) provided June 15, 2019.You asked the Plan to waive the copayment for the Emergency Room Services. You say that the copayment should be waived due to an error by the lab.The Plan denied your request. The Plan says the correct copayment was applied for the services rendered.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 Emergency Care. You have been asked to pay a $100 copayment for the Emergency Room Services. The Emergency Room Services 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 Services (99284) provided June 15, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the closed treatment of a fracture provided on July 27, 2019.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says there is a more appropriate code that has to be billed for the procedure.
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 28515 is closed treatment of fracture, phalanx or phalanges, other than great toe; with manipulation, each. 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 provided. Our reviewer says that the billed code does not meet criteria for billing or reimbursement consideration. The medical records provided do not include documentation of a closed treatment of fracture with manipulation being performed on July 27, 2019 Therefore, the billed service cannot be verified.
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 provided have not been met. Therefore, we decided that the Plan does not have to pay for the closed treatment of a fracture provided on July 27, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar sacral orthosis provided to the enrollee on November 29, 2019.You asked the Plan to pay for the orthosis. The Plan denied your request. The Plan says that there is no commensurate physical examination performed on or around that date showing why the brace was being ordered.The Plan must follow Medicare rules. Medicare rules say that a spinal orthosis is covered for the above indications.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the orthosis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. There are no clinical records in the case file that support that the spinal orthosis was ordered for one of the following indications: to reduce pain by restricting mobility of the trunk, or to facilitate healing following an injury to the spine or related soft tissues, or to facilitate healing following a surgical procedure on the spine or related soft tissue, or to otherwise support weak spinal muscles and/or a deformed spine. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for the orthosis.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the orthosis have not been met.Therefore, we decided that the Plan does not have to pay for the lumbar sacral orthosis provided to the enrollee on November 29, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires the best opportunity to get him back to an independent living status as previous. The Plan denied your request. The Plan says the enrollee is receiving appropriate care at the current acute care facility.
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 physician reviewer found LTACHs are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing care needs include respiratory support including tracheostomy care with oxygen supplementation, surveillance laboratory studies, tube feeding, sacral pressure wound care, and therapy services. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. 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.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care, 25 minutes (99309) provided on November 18, 2019 by an out of network (OON) provider.
You asked the Plan to pay for subsequent nursing facility care, 25 minutes by an OON provider. You say that the services were provided and payment should be rendered. The Plan denied your request. The Plan says prior authorization was not requested or received for the services, therefore coverage criteria has not been met.
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 subsequent nursing facility care, 25 minutes (99309) provided on November 18, 2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a chest x-ray (71045), set-up of portable x-ray equipment (Q0092), and transportation of portable x-ray equipment and personnel to home or nursing home (R0070) provided on November 14, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the chest x-ray, set-up of portable x-ray equipment, and transportation of portable x-ray equipment and personnel by an OON provider. You say that the services were provided and payment should be rendered. The Plan denied your request. The Plan says prior authorization was not requested or received for the services, therefore coverage criteria has not been met.
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 a chest x-ray (71045), set-up of portable x-ray equipment (Q0092), and transportation of portable x-ray equipment and personnel to home or nursing home (R0070) provided on November 14, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on January 2, 2020.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the services were obtained out-of-network and were not authorized by 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 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 physician's services provided on January 2, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room (ED) visit provided on January 10, 2020 by the providing facility.
You asked the Plan to waive the copayment for the ED visit. You say that you should not be responsible for the copayment since the services were not needed. 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 $90 copayment for emergency care. You have been asked to pay $73.73 (the allowed amount) for the ED visit. An ED 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 an emergency room (ED) visit provided on January 10, 2020 by the providing facility
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the infusion supplies for external drug infusion pump (A4222) and IV pole (E0776) provided June 8, 2019 to June 13, 2019.You asked the Plan to pay for the infusion supplies. You say that you have attached the hospital discharge order and medical records. Please review this and reprocess this claim for payment.The Plan denied your request. The Plan says the records provided 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 physician order for the items at issue in this appeal. The record does not contain a valid  physician order for the supplies provided in this case.Therefore, we decided that the Plan does not have to pay for the infusion supplies for external drug infusion pump (A4222) and IV pole (E0776) provided June 8, 2019 to June 13, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for chemotherapy provided from October 30,
2019 to November 8, 2019.
You asked the Plan to waive the coinsurance for chemotherapy. You say that you disagree with the charges.
The Plan denied your request. The Plan says the claims were processed correctly, and you are being charged
the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20%
coinsurance for Medicare Part B prescription drugs.
You have been asked to pay $102.38, which is less than the 20% coinsurance for chemotherapy. Chemotherapy
falls 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
coinsurance for chemotherapy provided from October 30, 2019 to November 8, 2019.