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

We decided that the Plan does not have to waive the copayment forthe Part B drug provided on January 30, 2020.You asked the Plan to waive the copayment forthe Part B drug. You say that you were told everything would be covered except the $50 specialist 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 20% coinsurance for Medicare covered Part B drugs and other Medicare covered items. You have been asked to pay $60 which is 20% of the allowed amount for the Part B drug. The allowed amount is $300. ($300 x 20% = $60). The Part B drug falls within the Medicare covered Part B drugs and other Medicare covered items 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 forthe Part B drug provided on January 30, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an X-ray provided on December 24, 2019.
You asked the Plan to waive the copayment for an X-ray. 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 $20
copayment for X-rays.
You have been asked to pay a $20 copayment for an X-ray. An X-ray falls within the outpatient diagnostic tests
and therapeutic services and supplies 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 X-ray provided on December 24, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the lab services you received on February 5, 2020.You asked the Plan to waive the co payment. The Plan denied your request. The Plan says you are responsible for the copayment.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 $10 copayment for Medicare-covered laboratory tests. Review of the file shows that you were provided lab services on February 5, 2020. You have been asked to pay a $10 copayment for the services. The services fall within the outpatient diagnostic tests 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 lab services you received on February 5, 2020.
Appeal type: SNF
Decision: Partially Favorable

We decided that the Plan has to reduce the copayment for the SNF stay. We decided that the Plan does not have to waive the copayment for the SNF stay.
You asked the Plan to waive the copayment for the SNF stay. You say that the member was under hospice care. You say that different bills are still being sent. The Plan says that the copayment applied correctly.
We decided that the Plan has to reduce the copayment for the SNF stay.
The Plan says that you must pay a $100 copayment for September 8, 2019. The records show that the enrollee was discharged on September 8, 2019. A copayment does not apply to the discharge date. Therefore, we decided that the Plan has to waive the $100 copayment for the discharge day.
We also decided that the Plan does not have to waive the copayment for the remaining SNF stay.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles, and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $20 copayment per day, per admission for days 1-20. Therefore, we decided that the Plan does not have to waive the $140 copayment for September 1, 2019 through September 7, 2019.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for a sinus endoscopy provided on November 19, 2019 by an out of network (OON) provider. You asked the Plan to pay for a sinus endoscopy. You say that you were not told that this provider was not
contracted. The Plan denied your request. The Plan says no prior authorization was obtained. 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 sinus endoscopy provided on November 19, 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 oxygenator assembly and operation services (CPT 99190) provided to the enrollee on January 10, 2020.You asked the Plan to pay for the services. You say that this should be paid for.The Plan denied your request. The Plan says payment for this service is the responsibility of the facility to any vendor.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 99190 is "Assembly and operation of pump with oxygenator or heat exchanger (with or without ECG and/or pressure monitoring); each hour."We find that CPT code 99190 is not supported in the medical record. Specifically, payment for this code is included in the payment to the facility. 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 oxygenator assembly and operation services (CPT 99190) provided to the enrollee on January 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for lumbar-sacral orthosis (L0650) shoulder orthosis (L3670) and ankle foot orthosis (L1906x2) provided December 6, 2019. You asked the Plan to pay for the orthoses. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says there is no evidence of an established relationship between the enrollee and the ordering physician, there was no claims submitted for an evaluation and management service and there is no evidence of a prior telehealth service with the ordering physician as required per CMS guidelines. The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the non-covered visit are likewise non-covered. Therefore, we decided that the Plan does not have to pay for lumbar-sacral orthosis (L0650) shoulder orthosis (L3670) and ankle foot orthosis (L1906x2) provided December 6, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve physical therapy. You say that you have enjoyed your long relationship with this provider and do not want that to end. The Plan denied your request. The Plan says the denial of authorization for these services is correct, because this provider is out-of-network with the Plan and you can be treated by an in-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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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-approve the medical services to be provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on January 2, 2020.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 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 documentation of the ordering physician's intent that the tests 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 the drug testing services provided on January 2, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray (71275) provided on January 14, 2020.
You asked the Plan to pay for the x-ray. You say that you would like reconsideration as this claim was billed corrected. The Plan denied your request. The Plan says this claim was billed as emergency room but should have been billed as inpatient.
The Plan must follow Medicare rules. Medicare rules say that a physician/practitioner/supplier furnishing services to a patient who is a registered inpatient, shall, at a minimum, report the inpatient hospital POS code 21 irrespective of the setting where the patient actually receives the face-to-face encounter. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the x-ray have not been met. Specifically, the record indicates that the member was in an inpatient stay on this date of service. The claim has been submitted with an emergency room place of service code but per Medicare rules, the inpatient place of service code should be reported. Therefore, we decided that the Plan does not have to pay for an x-ray (71275) provided on January 14, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 0042T) provided on November 13, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. Medicare rules say that A56480 provides a list of non-covered CPT Category III Codes. We looked at the file and Medicare rules. The requested code, 0042T, is considered non-covered per LCA A56480. 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 (CPT 0042T) provided on November 13, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home exercise equipment, a bench press and stationary bike.
You asked the Plan to pre-approve home exercise equipment. You say that you are not able to walk due to a torn muscle and feels that you should be able to use your gym membership allowance to purchase the stationary bike and bench press. The Plan denied your request. The Plan says home exercise equipment is not covered by Medicare or the plan.
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 pre-approve home exercise equipment, a bench press and stationary bike.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the bladder catheter insertion rendered on December 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 procedure code 51701 is not separately payable.The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.The provider submitted a claim for procedure codes 51701 and 51729. Code 51701 is a column II code with a modifier indicator of 1 when billed with column I code 51729. Code 51701 was not billed with an appropriate modifier to allow for separate payment. Please note that the Plan has reprocessed the claim for these services with zero responsibility to you.Therefore, we decided that the Plan does not have to pay for the bladder catheter insertion rendered on December 18, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided for the insertion of a leadless pacemaker on December 23, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. Medicare rules say that leadless pacemakers are non-covered when furnished outside of a CMS approved CED study. We looked at the file and Medicare rules. The requested services were provided for the insertion of a leadless pacemaker. The records do not show that the leadless pacemaker was provided as part of a CMS approved CED study. 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 provided for the insertion of a leadless pacemaker on December 23, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe critical care services coded 99291 provided from October 10, 2019 to October 31, 2019.You asked the Plan to pay for[Shorter description of ITEM or SERVICE at issue, e.g. "a power wheelchair"]. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not supported by the documentation.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes.We find that CPT code 99291 is not supported in the medical record. Specifically, the documentation submitted did not support a critical care visit of 30-74 minutes was performed on these dates of service. Based on this information, we decided that Medicare rules for coverage of [Shorter description of ITEM or SERVICE at issue, e.g. "a power wheelchair"] have not been met.Therefore, we decided that the Plan does not have to pay forthe critical care services coded 99291 provided from October 10, 2019 to October 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump with an oxygenator or heat exchanger (99190) provided on January 10, 2020.
You asked the Plan to pay for the assembly and operation of a pump with an oxygenator or heat exchanger. You say that this was a required service. The Plan denied your request. The Plan says payment for this service is included in the DRG.
The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that CMS designates to be "inpatient-only" services. These services have an OPPS status indicator of "C" in the OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule. The service at issue in this appeal was billed with CPT code 99190. This code is listed with a status indicator of
"C" on Addendum B of the 2020 OPPS/ASC final rule. This means the service has been designated as "inpatient only", and therefore must be billed as part of an inpatient admission. Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump with an oxygenator or heat exchanger (99190) provided on January 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthosis (L1833) and suspension sleeve (L2397) provided to the enrollee on December 19, 2019.You asked the Plan to pay for the orthosis and sleeve. You say that the durable medical equipment is medically necessary.The Plan denied your request. The Plan says they were unable to discover any evidence of an established relationship between the member and the ordering physician. The Plan states there were no claims submitted for an evaluation and management service. The Plan states the review of claims history for this member, and a review of the submitted documentation does not contain evidence of a prior Telemedicine or Telehealth service with the ordering physician as required per CMS guidelines.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 and sleeve. Our reviewer says that the enrollee does not meet criteria for the orthosis and sleeve ordered. Our physician reviewer found the documentation in the case file does not support that the requested knee orthoses with sleeves were medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. There is no documentation of recent injury to, or recent surgical procedure on, either of the enrollee's knees, and there is insufficient credible objective documentation of joint laxity. The item coded L2397 (sleeve) is not separately payable when the base item is not covered.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 and sleeve have not been met.Therefore, we decided that the Plan does not have to pay for knee orthosis (L1833) and suspension sleeve (L2397) provided to the enrollee on December 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on October 21, 2019.You asked the Plan to waive the copayment for the office visit. You say that it is a mistake to be charged a specialist copayment. You say that it should be overturned for a follow up visit.The Plan denied your request. The Plan says that 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 $45 for each Medicare-covered. You have been asked to pay a $45 copayment for the office visit. The office visit falls within the "Podiatry services" benefit category. There is no provision in the contract which indicates a copayment would be waived for services performed as a follow-up. 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 office visit provided on October 21, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete lower denture (D5120) provided on September 12, 2019.You asked the Plan to pay for the dental item. You say that you did not know that dentures were only covered once every 5 years. You also say that you could not get your denture adjusted because the original provider is no longer in business.The Plan denied your request. The Plan says dentures are covered once every 5 years. The Plan also says the frequency limit 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 and dentures are a covered service, the frequency limit for dentures has been exceeded. The record shows that the Plan paid for a complete lower denture that you received on February 1, 2017.Therefore, we decided that the Plan does not have to pay for the complete lower denture (D5120) provided on September 12, 2019.