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

We decided that the Plan does not have to pre-approve Dupixent Injection 300/2ml for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says this medication does not fall under Part B coverage.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-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 pre-approve Dupixent Injection 300/2ml for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for blood glucose/reagent strips (A4253) lancets (A4259) calibrator solution/chips (A4256) lithium battery for glucose monitor (A4235) provided on May 21, 2019 to August 9, 2019.You asked the Plan topay forthe diabetic supplies. You say that the records should support the necessity of the services billed.The Plan denied your request. The Plan says the records do not support the supplies 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 proof of delivery documentation for the items at issue in this appeal. The record does notcontain a valid proof of delivery for the supplies provided in this case. The delivery ticket submitted did not include the carrier's tracking number and the proof of delivery did not include an order number or details to corroborate the delivery ticket submitted.Therefore, we decided that the Plan does not have to pay forblood glucose/reagent strips (A4253) lancets (A4259) calibrator solution/chips (A4256) lithium battery for glucose monitor (A4235) provided on May 21, 2019 to August 9, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ED visit provided on August 29, 2019.
You asked the Plan to waive the copayment for the ED visit. You say that some of the care could have been done in the urgent care. You say that you shouldn't have to pay for poor service. The Plan denied your request. The Plan says the copayment applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 copayment per visit. You have been asked to pay a $90 copayment for the ED visit. The ED visit falls within the "Emergency care" benefit category. The records show that you received services in the ED. 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 ED visit provided on August 29, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 99190) provided to the beneficiary  We decided that the Plan does not have to pay for the services (CPT 99190) provided to the beneficiary on June 18, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment for this service is the responsibility of the facility.
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. Payment for all fees related to this service would have been included under the facility claim. Therefore, we decided that the Plan does not have to pay for the services (CPT 99190) provided to the beneficiary on June 18, 2019. on June 18, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment for this service is the responsibility of the facility.
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. Payment for all fees related to this service would have been included under the facility claim. Therefore, we decided that the Plan does not have to pay for the services (CPT 99190) provided to the beneficiary on June 18, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance ride provided on September 14, 2019.
You asked the Plan to waive the copayment for the ambulance ride. You say that you will not pay the copayment because you were not taken to your preferred hospital. 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 per date of service regardless of the number of trips for emergency and non-emergency in- and out-of-network ambulance services. You have been asked to pay a $100 copayment for the ambulance ride. The ambulance ride falls within the "Ambulance 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 the ambulance ride provided by on September 14, 2019.
Your complaint that the EMS staff did not listen to you 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing rendered on April 10, 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 there is no valid physician order.We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan doesnot have to pay forthe drug testing rendered on April 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on August 7, 2019 by out of network provider. You asked the Plan to pay forphysician services. You say that while we admit we may have been remiss about the authorization, we did attempt to get it and this was medically necessary.The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the member's primary care physician did not refer for 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 medical services provided on August 7, 2019 by out of network provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe medical services to be provided by out of network provider.You asked the Plan to pre-approvean outpatient surgery. You say that you are the only doctor who can perform this surgery.You say that you were referred by the enrollee's in-network provider.The Plan denied your request. The Plan says there are in-network providers who can perform the service in question.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 pre-approve 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. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approvethe medical services to be provided by out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite provided on September 10, 2019.You asked the Plan to pay forthe resin-based composite. You say that you thought cavities were included under your Plan's policy. You also say that you did not realize that you were limited to only 2 procedures.The Plan denied your request. The Plan says the benefits for this service have been satisfied and the frequency limitation has been exceeded.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, restorations (or amalgams and resin-based composites) are limited to two procedures per calendar year. The record shows that you received one resin-based composite on July 2, 2019 and a second resin-based composite on August 6, 2019 and your restorations benefit was then exhausted.Therefore, we decided that the Plan does not have to pay for the resin-based composite provided on September 10, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for x-ray services provided on July 12, 2019.
You asked the Plan to pay for the x-ray services. The Plan denied your request. The Plan says non-urgent, non-emergent services require prior authorization. The Plan requires utilization of network providers when possible and available.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan 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 x-ray services provided on July 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies rendered to the enrollee on August 26, 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 codes K0554 and K0553 must be billed with modifier KX if the beneficiary is insulin-treated or modifier KS if they are non-insulin treated. We looked at the file and Medicare rules. The file shows that code K0554 was billed with the NU modifier and K0553 with the KX modifier. Code K0554 was billed with an inappropriate modifier and is not payable. Code K0553 was billed with the correct modifier; however, it is not payable, as the code is for supply allowance the supplies code of K0554 is not payable. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies rendered to the enrollee on August 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the special pump services rendered to the enrollee on June 18, 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 services are not covered.
The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of X are statutorily excluded. The provider submitted a claim for procedure code 99190 (special pump services). This code has a status indicator of X and no separate Medicare payment. Payment is included in the payment to the facility. Therefore, we decided that the Plan does not have to pay for the special pump services rendered to the enrollee on June 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 19, 2019 by out of network provider.
You asked the Plan to pay for physician services. You say that the doctor was assigned this patient. You say that the doctor is not aware of the patient's insurance when he sees the patient, and accepts the responsibility to care for the patient. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the referring provider is an out-of-network provider.
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 July 19, 2019 by out of network provider.
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 there are very limited options for the enrollee, and the LTACH is the best situation for the enrollee to improve. The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found as LTACHs and acute care hospitals are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current acute care hospital until such time as no acute care services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long-term care needs. 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on August 27, 2019.
You asked the Plan to pay for the pump assembly and operation. You say that it takes a half hour to an hour to set up the Heart Lung Machine and the perfusionist is required to be in the operating room during the length of the procedure. The Plan denied your request. The Plan says payment for this service would be included in the Part-A DRG payment to the facility.
The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the pump assembly and operation have not been met. Specifically, the payment for this service is included in the DRG payment to the facility. Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on August 27, 2019.
Appeal type: Lab
Decision: Partially Favorable

We decided that the Plan does not have to pay for the drug testing rendered to the enrollee on April 22, 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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 drug testing rendered to the enrollee on April 22, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for initial observation care (99219) provided by the doctor.
You asked the Plan to pay for initial observation care. You say that all services rendered to the enrollee was a medical necessity at the time of service. Please reconsider payment. The Plan denied your request. The Plan says this service exceeds the maximum number allowed per day.
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 billing of code 99219 was submitted inappropriately due to the bundled relationship of services within the specialty group. This code can only be billed once per day. Based on Medicare billing guidelines, this claim cannot be paid as billed. Therefore, we decided that the Plan does not have to pay for initial observation care (99219) provided by the doctor.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance services on May 3, 3019.
You asked the Plan to waive the copayment for the ambulance services. You say that you were told by the provider there would not be a copayment. The Plan denied your request. The Plan says you were charged this copayment 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 $210 copayment per trip for Ambulance Services. You have been asked to pay $210 copayment for the ambulance services. 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 ambulance services provided on May 3, 3019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services provided by an out-of-network provider on August 14, 2019.You asked the Plan to pay for the services. You say that the services were medically necessary.The Plan denied your request. The Plan says the services were not authorized.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 services.Therefore, we decided that the Plan does not haveto pay forthe services provided by an out-of-network provider on August 14, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for paramedic intercept services provided on February 28, 2019.
You asked the Plan to pay for paramedic intercept services. You say that the paramedic intercept services were medically necessary. The Plan denied your request. The Plan says paramedic intercept services are not covered by Medicare in urban areas.
The rules say that Medicare pays for advanced life support (ALS) paramedic intercept services only when the services are furnished in a rural area. The paramedic intercept services at issue in this appeal were not furnished in a rural area. Therefore, we decided that the Plan does not have to pay for paramedic intercept services provided on February 28, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ambulance trip provided by Athens Limestone Health Services on May 22, 2019.
You asked the Plan to waive the copayment for an ambulance trip. 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 a $200 copayment for ambulance services. You have been asked to pay a $200 copayment for an ambulance trip. An ambulance trip falls within the ambulance 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 an ambulance trip provided by Athens Limestone Health Services on May 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on June26, 2019.You asked the Plan to pay forthe subsequent nursing facility care. You say that the enrollee was treated while hospitalized. You say that medically necessary services wereprovided to the enrollee in good faith.The Plan denied your request. The Plan says services from non-participating providers are not covered unless they are authorized by the Plan before the services are provided.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 servicesat 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 forsubsequent nursing facility care provided on June26, 2019.