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

We decided that the Plan does not have to pay for the medical services provided on September 9, 2019 by out of network provider.
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and approved for payment. 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 assisted living facility is out-of-network. 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 September 9, 2019 by out of network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an MRI procedure (76498) provided on June 24, 2019.
You asked the Plan to pay for the MRI procedure. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the submitted medical records and claim form do not indicate the name of the unlisted magnetic resonance procedure performed.
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 76498 is Unlisted magnetic resonance procedure (eg, diagnostic, interventional). 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 MRI procedure. Our reviewer says that unlisted CPT code 76498 is not supported by the medical record. Our physician reviewer found the record states that an MRI of the pelvis, with and without contrast, was performed. According to CPT rules, there is a specific code for this procedure. The record does not contain evidence that a separately identifiable procedure that is not described by a specific CPT code was also performed during this episode of care. 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 MRI procedure have not been met. Therefore, we decided that the Plan does not have to pay for an MRI procedure (76498) provided on June 24, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for vehicle modifications (T2039) provided March 20, 2019 to June 21, 2019.
You asked the Plan to pay for vehicle modifications. You say that recently the van lift quit working and
requires a new hydrolic pump and you would like help with the expenses. The Plan denied your request. The
Plan says van equipment repair 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 vehicle modifications (T2039) provided March 20, 2019 to June 21, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code G0482 provided on June 27, 2019.
You asked the Plan to pay for CPT code G0482. You say that you would like the plan to reconsider their denial of payment. The Plan denied your request. The Plan says the medical records do not support the billing of CPT code G0482.
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 G0482 is Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21 drug class(es), including metabolite(s) if performed. We find that CPT code G0482 is not supported in the medical record. Specifically, the record does not contain evidence that definitive testing on 15-21 drug classes was performed. Therefore, we decided that the Plan does not have to pay for CPT code G0482 provided on June 27, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyewear purchased from an out-of-network provide on July 22, 2019.
You asked the Plan to pay for the eyewear. You say that you contacted the Plan on July 23, 2019 to inquire about your vision benefit and you were told by the representative that you were able to use a provider as a participating provider for your vison exam. You state that you told the representative that a provider uses a provider to make the frames and lens' for them and you were never advised that the provider was not a participating provider to be able to use the glasses portion of your vision benefit. The Plan denied your request. The Plan says the provider is not a participating provider.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the eyewear have not been met. The OON provider is not a participating provider with the OON provider and is listed at a separate location. Therefore, coverage for the eyewear obtained on July 22, 2019 cannot be provided. Therefore, we decided that the Plan does not have to pay for the eyewear purchased from an out-of-network provide on July 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for anesthesia provided on September 23, 2019.
You asked the Plan to waive the coinsurance for anesthesia. You say that this claim should be covered in full. 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 30% coinsurance for out-of-network physician/practitioner services, including doctor's office visits. You received anesthesia on September 23, 2019. The allowed amount is $129.23 and 30% of that is $38.77. You have been asked to pay the total coinsurance amount of $38.77 for anesthesia. Anesthesia falls within the physician/practitioner services, including doctor's office visits 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 anesthesia provided on September 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on June 26, 2019 to July 10, 2019 by out of network (OON) provider.
You asked the Plan to pay for the wound care services. You say that the services were provided prior to obtaining authorization to avoid delay in care which could result in wound complications including deterioration, amputation, infection and or hospitalization. The Plan denied your request. The Plan says the provider had opportunity to request authorization to provide the rendered services. Network providers are available to provide this care. Non-emergency unauthorized care is not covered when provided OON.
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 June 26, 2019 to July 10, 2019 by out of network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy services provided to the enrollee from July 28, 2019 to August 4, 2019.
You asked the Plan to pay for the therapy services. You say that the plan is inconsistent with reasons to pay for services. The Plan denied your request. The Plan says the billed code is not valid for Medicare purposes.
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 S9328 is home infusion therapy, implanted pump pain management infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment. We find that CPT code S9328 is not supported. Specifically, Medicare uses another code for the reporting of, and payment for, these services. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy services provided to the enrollee from July 28, 2019 to August 4, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided from August 4, 2019 through August 7, 2019.
You asked the Plan to pay for these drugs. You say that you were not told to bring your medications to the hospital. The Plan denied your request. The Plan says that these drugs are not covered under Part B.
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 pay for the self-administered drugs provided from August 4, 2019 through August 7, 2019.
Benefits for these drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an echocardiography provided on July 18, 2019.
You asked the Plan to waive the copayment for an echocardiography. You say that you have never been charged by this provider in the past. 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 $75 copayment for ultrasounds. You received an echocardiography on July 18, 2019. Echocardiographs are considered ultrasounds. Therefore, you are responsible to pay the $75 copayment. You have been asked to pay a $75 copayment for an echocardiography. An echocardiography 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 echocardiography provided on July 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the glucose monitor, test strips, lancets, control solution, and lancet device provided from July 23, 2019 to October 11, 2019.
You asked the Plan to pay for the glucose monitor (E0607), test strips (A4253), lancets (A4259), control solution (A4256), and lancet device (A4258). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered. Therefore, we decided that the Plan does not have to pay for the glucose monitor, test strips, lancets, control solution, and lancet device provided from July 23, 2019 to October 11, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services provided on August 15, 2019.
You asked the Plan to pay for the inpatient hospital services. You say that the claim has not been paid in full or under the terms of the contract of the services provided to the enrollee. The Plan denied your request. The Plan says the Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services provided on August 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ocular health exam provided on August 1, 2019.
You asked the Plan to waive the copayment for the ocular health exam. You say that you were under the impression that you would not pay anything for the follow up appointment for the cataract surgery. 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 $40 copayment for in-network subsequent visits. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $40 copayment for the ocular health exam.
You have been asked to pay $19.19 copayment for the ocular health exam. The ocular health exam falls within the "Vision services" benefit category. There is no provision in the contract which indicates a copayment would be waived if performed as a follow-up to a surgical procedure.
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 ocular health exam provided on August 1, 2019.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to waive the copayment for a colonoscopy provided on May 20, 2019.
You asked the Plan to waive the copayment for a colonoscopy. You say that this was a colonoscopy screening
and you should not be responsible for the charges. The Plan denied your request. The Plan says that 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. Your
contract with the Plan says that there is no coinsurance, copayment or deductible for colorectal cancer
screenings.
You received a colonoscopy on May 20, 2019. The plan did not provide medical records or any other
documentation showing that the colonoscopy was diagnostic or that polyps were removed.
The Plan says you must pay a $50 copayment for a colonoscopy. Based on the Plan contract, however, you
cannot be asked to pay for a colonoscopy screening. Therefore, we decided that the Plan has to waive the
copayment for a colonoscopy provided on May 20, 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care, per day, for the evaluation and management of a patient (99307) provided on July 12, 2019.
You asked the Plan to pay for subsequent nursing facility care. You say that the services were provided and payment should be rendered. The Plan denied your request. The Plan says based on the documentation provided, the claim was processed correctly.
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the enrollee's medical records and confirm that Medicare coverage criteria have been met. We looked at the file and Medicare rules. Specifically, medical records were not provided. The services are not able to be corroborated without this documentation. Based on this information, we decided that Medicare rules for coverage of subsequent nursing facility care have not been met. Therefore, we decided that the Plan does not have to pay for subsequent nursing facility care, per day, for the evaluation and management of a patient (99307) provided on July 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lift chair and seat lift mechanism provided on September 19, 2019.
You asked the Plan to pay for the DME. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says the Medicare rules have not been met. The Plan states for you, the additional accessories (battery, charger and back pack) for your portable oxygen concentrator are not needed in the home. The Plan states you have a portable oxygen system and a home oxygen system with the batteries and chargers; therefore, the back pack is not covered by Medicare.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. Although your plan does not allow coverage for the lift chair, coverage for the seat lift mechanism may be provided. A participating provider is required to request authorization for the seat lift mechanism through the plan.  After speaking with the participating provider, it was determined that authorization was not requested, and you were advised that you would need to pay out of pocket for the chair and mechanism. Therefore, you will not be held liable for the $225.27 that applied for the seat mechanism and it will be denied to the provider. You will be issued a refund by the provider for this item. You will remain liable for the $764.72 that applied for the lift chair which is not a covered item by the Plan or Medicare. Therefore, we decided that the Plan does not have to pay for the lift chair and seat lift mechanism provided on September 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the EZ Access Trifold Advantage Series portable wheelchair ramp purchased on August 12, 2019.
You asked the Plan to reimburse you for the wheelchair ramp. You say that the ramp is necessary to have the home handicap accessible. The Plan denied your request. The Plan says Medicare does not cover equipment outside the home or home modifications.
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. Neither Medicare nor the Plan cover wheelchair ramps. Therefore, we decided that the Plan does not have to reimburse you for the EZ Access Trifold Advantage Series portable wheelchair ramp purchased on August 12, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided to the enrollee on September 6, 2019 by the out of network provider.  You asked the Plan to pay for the out-of-network services. You say that this out-of-network provider is the only provider of the billed test. The Plan denied your request. The Plan says services rendered by non-participating providers require prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for the services. Therefore, we decided that the Plan does not have to pay for the lab services provided to the enrollee on September 6, 2019 by the out of network provider.