Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pay forthe diabetic testing supplies provided from August 5, 2019 to October 24, 2019.You asked the Planto pay forthe testing supplies. You say that the documentation provided supports that this claim should be paid.The Plandenied your request. The Plansaysthe proof of delivery documentation is not sufficient.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 does not contain a valid proof of delivery for the supplies provided in this case. The delivery ticket does not have the carrier tracking number documented nor does the delivery confirmation reference the order number. The documents are not sufficient to support that the supplies at issue were in fact delivered.Therefore, we decided that the Plandoes not haveto pay forthe diabetic testing supplies provided from August 5, 2019 to October 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar injection provided on April 11, 2019 by out of network provider.You asked the Plan to pay for the surgical service. You say that you were advised by a Plan representative on April 5, 2019 that pre-authorization was not needed for this procedure.The Plan denied your request. The Plan says the enrollee was referred for the services by another out of network provider. The Plan says that authorization was not obtained before the services were rendered to the enrollee. The Plan also says there is no record of an urgent or emergent situation.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 provider in this case is not a network provider with the Plan. The referring provider is not a network provider either. 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 lumbar injection provided on April 11, 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 to the enrollee and billed under code G0483.You asked the Plan to pay for this service. You say that this claim should be paid.The Plan denied your request. The Plan says Medicare coverage criteria were not met.The Plan must follow Medicare rules. Medicare has specific documentation requirements for this type of testing. The physicians order and the medical records must specifically show how this testing will be used to treat illness or disease present in the enrollee at the time of service as opposed to this testing being done for screening purposes. Based on the records provided, the required Medicare criteria are not met. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee and billed under code G0483.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe glucose monitor, test strips, lancets, control solution, and lancet device provided by the provider on May 24, 2019.You asked the Plan to pay forthe glucose monitor (E2100),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 theProof 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 Planmade 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 forthe glucose monitor, test strips, lancets, control solution, and lancet device provided on May 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe diabetic supplies rendered to the enrollee by the provider on August 17, 2019 to November 5, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says there is no proof of delivery.The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS suppliers are required to maintain proof of delivery.We looked at the file and Medicare rules. The documentation does not contain valid proof of delivery for the supplies at issue. 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 forthe diabetic supplies rendered on August 17, 2019 to November 5, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe dental services provided from January 30, 2019 to March 7,2019.You asked the Plan to pay for the dental services. You say that you were told the dental services were approved by insurance.The Plan denied your request. The Plan says the services are not covered benefits.Medicare generally does not cover dental services. The Plan follows the same rule.The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. The record shows you did not elect to sign up for the Optional Supplemental Dental Benefit. See chart below.Date of ServiceServicePlan BilledAllowed AmountMember LiabilityJanuary 30, 2019Periodic oral evaluation$120.00$0.00$120.00January 30, 2019Periapical x-rays$30.00$0.00$30.00February 7, 2019Periodic oral evaluation$120.00$0.00$120.00February 7, 2019Bitewing x-rays$40.00$0.00$40.00February 7, 2019Additional periapical x-ray$25.00$0.00$25.00February 7, 2019Additional periapical x-ray$25.00$0.00$25.00February 7, 2019Additional periapical x-ray$25.00$0.00$25.00February 7, 2019Additional periapical x-ray$25.00$0.00$25.00
Date of ServiceServicePlan BilledAllowed AmountMember LiabilityFebruary 7, 2019Additional periapical x-ray$25.00$0.00$25.00February 7, 2019Additional periapical x-ray$25.00$0.00$25.00February 7, 2019Cleaning$170.00$0.00$170.00February 14, 2019Periodontal scaling and root planning$180.00$0.00$180.00February 14, 2019Periodontal scaling and root planning$180.00$0.00$180.00February 14, 2019Periodontal scaling and root planning$180.00$0.00$180.00February 14, 2019Periodontal scaling and root planning$180.00$0.00$180.00February 25, 2019Resin-based filling$90.00$0.00$90.00February 25, 2019Resin-based filling$90.00$0.00$90.00March 1, 2019Resin-based composite$100.00$0.00$100.00March 7, 2019Resin-based composite$100.00$0.00$100.00March 7, 2019Resin-based composite$100.00$0.00$100.00Total$1,830.00Therefore, we decided that the Plan does not have to pay for the dental services provided from January 30, 2019 to March 7, 2019
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CT scan provided on October 1, 2019.
You asked the Plan to waive the copayment for the CT scan. You say that if the Plan pre-approved the CT scan you would have only paid one copayment. You say that the copayment should be waived. 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 $175 copayment per provider, per date of service for complex radiology from an in-network provider. You have been asked to pay a $175 copayment for the CT scan. The CT scan 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 the CT scan provided on October 1, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on March 4, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the physician order is invalid.
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 and proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid physician order nor a proof of delivery for the supplies provided in this case. The physician order lacks required detail, including date of service. Additionally, there is no itemized delivery ticket. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on March 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for oxygenator assembly and operation services provided on July 25, 2019.
You asked the Plan to pay for these services. You say that the services performed were medically necessary, and were for the perfusionist that setup and operated the heart-lung machine for the surgery. The Plan denied your request. The Plan says the enrollee received the services in the facility during inpatient hospitalization, and 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 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 would be included in the payment to the facility, and cannot be coded separately. 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 provided on July 25, 2019.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to pay for the 155 units of 01480. We decided that the Plan does not have to pay for the femoral nerve block. You asked the Plan to pay for the 155 units of 01480. You say that the documentation supports the billed services.The Plan says that the time units billed are not supported by the record. There is also no evidence that a femoral nerve block was performed.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the annual wellness visit rendered to you on August 1, 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 exceed the benefit limit.The Plan must follow Medicare rules. Medicare rules say that an annual wellness visit is covered once every 12 months. The contract with the Plan says that you may receive an annual wellness visit once every calendar year.The file shows that you had an annual wellness visit on August 1, 2019. You previously received these services on April 25, 2019 for which the Plan approved and paid. The services on August 1, 2019 were performed within the same calendar year as your previously covered annual wellness visit.Therefore, we decided that the Plan does not have to pay forthe annual wellness visit rendered to you on August 1, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodontal maintenance provided on July 24, 2019.

You asked the Plan to pay for periodontal maintenance. You say that the plan provides for two periodic oral evaluations per year. You say that you were assured you had dental coverage when you switched plans. The Plan denied your request. The Plan says this is not a covered benefit.

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 periodontal maintenance provided on July 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the diabetic supplies provided to the enrollee from June 25, 2019 to September 13, 2019.
You asked the Plan to pay for the diabetic supplies. The Plan denied your request. The Plan says that valid proof of delivery was not submitted.
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 tracking ticket does not include the items supplied and the delivery ticket does not include a tracking number to confirm it was delivered. Therefore, we decided that the Plan does not have to pay for the diabetic supplies provided to the enrollee from June 25, 2019 to September 13, 2019
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit from July 27, 2019 to July 28, 2019.
You asked the Plan to waive the copayment for the emergency room visit. 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 $90 copayment for each emergency room visit. You have been asked to pay a $90 copayment for the emergency room visit. The emergency room 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 the emergency room visit from July 27, 2019 to July 28, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe surgical services rendered to the enrollee by the provider on October 31, 2018.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 38571 is not supported.The Plan must follow Medicarerules. 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 38571 is laparoscopy, surgical; with bilateral total pelvic lymphadenectomy.We find that CPT code 38571 is not supported in the medical record. Specifically, the operative report does not include documentation of a surgical laparoscopy as described by this code. Based on this information, we decided that Medicare rulesfor coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay forthe surgical services rendered on October 31, 2018.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for Skilled Nursing Facility (SNF) services provided.
You asked the Plan to pay for the SNF services. You say that the SNF services were medically necessary. The
Plan denied your request. The Plan says the services were not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above are met. Custodial care is not covered.
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 SNF services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found this patient did not require skilled
nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse. The patient
did not have complex wound care or other SNF level skilled nursing 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 SNF services have not been met. Therefore, we decided that the Plan does
not have to pay for Skilled Nursing Facility (SNF) services provided.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plandoes not haveto pay forhome health services received from January 6, 2019 to May 1, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysno skilled services were ordered, and the enrollee is not homebound.ThePlan must follow Medicare rules. The rules say that an enrollee must be homebound for home health care services to be covered. 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 home health services received from January 6, 2019 to May 1, 2019.. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found in this case, there is no indication the patient is home-confined. As such, the necessity for home health care services is not substantiated. Therefore, this request is not medically necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plandoes not haveto pay forhome health services received from January 6, 2019 to May 1, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete maxillary denture (code D5110), complete mandibular denture (code D5120), 2 extractions (code D7210), 2 removals of lateral exostosis (code D7471), and 2 subsequent 15 minute increments of sedation or anesthesia (code D9223) provided on March 5, 2016 and March 28, 2016You asked the Plan to pay for the complete maxillary and mandibular dentures, extractions, removals of lateral exostosis, and subsequent 15 minute increments of sedation or anesthesia. You say that you had x-rays which showed you needed surgery to file down bone so that the denture would fit properly. You also say that your dentures broke, never fit, and you need to get new dentures.The Plan denied your request. The Plan says there are changes in bone and gum structure to make dentures loose where the fit is not as good as when they were initially provided. The Plan also says that there were no records provided from the current dentist to provide any information.
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. The Plan covers the complete maxillary and mandibular dentures, extractions, removals of lateral exostosis, and subsequent 15 minute increments of sedation or anesthesia when the services are medically necessary and reasonable. 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 complete maxillary and mandibular dentures, extractions, removals of lateral exostosis, and subsequent 15 minute increments of sedation or anesthesia. Our reviewer says that the services were not medically necessary. Our physician reviewer found that coverage is allowed once every five years. Our reviewer found that in this case, the required time has not been met. Our physician reviewer also found that the services provided in 2016 appear to be the standard of care applied in an expeditious manner.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the complete maxillary and mandibular dentures, extractions, removals of lateral exostosis, and subsequent 15 minute increments of sedation or anesthesia have not been met.Therefore, we decided that the Plan does not have to pay forthe complete maxillary denture (code D5110), complete mandibular denture (code D5120), 2 extractions (codeD7210), 2 removals of lateral exostosis (code D7471), and 2 subsequent 15 minute increments of sedation or anesthesia (code D9223) provided on March 5, 2016 and March 28, 2016This decision does not address any prior authorization for new dentures. This decision is solely based on the reimbursement of the dentures received in March 2016. For information on prior authorization for new dentures, please contact the Plan
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient skilled nursing facility care (SNF) provided from June 25, 2019 to July 24, 2019.You asked the Plan to pay for these services. You say that the provider is a Medicaid agency authorized to pursue Medicare claims for services provided to dually eligible Medicare and Medicaid beneficiaries and for which the state Medicaid program has paid.The Plan denied your request. The Plan says the services provided do not meet Medicare criteria for coverage of inpatient SNF services.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.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 these services. Our reviewer says that the services provided do not meet Medicare criteria for coverage of inpatient skilled nursing facility care. Our physician reviewer found the beneficiary does not require skilled nursing or therapy services on a daily basis. Additionally, the beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.
We looked at this physician's review, the file, and Medicare rules. 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 inpatient skilled nursing facility care (SNF) provided June 25, 2019 to July 24, 2019