Persius/hicric huggingface dataset:
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 17, 2019 to October 5, 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 17, 2019 to October 5, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plandoes not haveto pay foroxygenator assembly and operation services provided to the enrollee on July 8, 2019.You asked the Planto pay forthe services. You say that CPT 99190 is for the setup and operation of the Heart Lung machine for the enrollee's open heart surgery.The Plandenied your request. The Plansayspayment 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.We find that CPT code 99190 is not supported in the medical record. Specifically, 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 Plandoes not haveto pay foroxygenator assembly and operation services provided on July 8, 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 11, 2019 to September 29, 2019.You asked the Plan to pay for the 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 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 and 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 11, 2019 to September 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pay forthe physical exam provided on July 29, 2019.You asked the Planto pay forthe physical exam. You say that you had to go to this second physical because you feel that the other one you had earlier was not professional and was incomplete.The Plandenied your request. The Plansaysyou received two physicals for the year. The second physical was correctly denied as you had exhausted this benefit.The Plan must follow Medicare rules. Medicare rules say that only one annual wellness visit is covered. Your Plan covers one full physical as well.In this case, you received a full physical on May 13, 2019. This means you had exhausted this benefit for the year.Therefore, we decided that the Plandoes not haveto pay forthe physical exam provided on July 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foranesthesia services (01992) provided on July 9, 2019.You asked the Plan to pay for the anesthesia services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says there was not sufficient information submitted to determine how the member came to the servicing provider or whether the services are medically necessary.The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the anesthesia services have not been met. Please note, the record indicates that the Plan made multiple attempts to obtain medical records. Without records, it is not possible to determine how the member came to the servicing provider or whether the services were medically necessary. Therefore, we decided that the Plan does not have to pay for anesthesia services (01992) provided on July 9, 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 June 17, 2019 to September 5, 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 June 17, 2019 to September 5, 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 (99190) provided on June 28, 2019.You asked the Plan to pay for the pump assembly and operation. You say that the perfusionist assembles and operates the pump and remains present throughout the entire procedure. The Plan denied your request. The Plan says this is a Part A benefitwhile an inpatient admission and are included in the facility DRG.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 rulesfor 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 June 28, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for test strips (A4253), lancets (A4259), control solution (A4256), and batteries (A4235) provided from July 23, 2019 to October 11, 2019.
You asked the Plan to pay for test strips (A4253), lancets (A4259), control solution (A4256), and batteries (A4235). 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 test strips (A4253), lancets (A4259), control solution (A4256), and batteries (A4235) provided from July 23, 2019 to October 11, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for (D0350), (D5820), (D5821), (D1206), (D4999), (D9230) and (D7953) provided.
You asked the Plan to pay for the dental services. You say that you lost the cap on the front tooth and wanted to replace the cap. You state the dentist said more work would be required and that you ended up getting a credit card to pay for services. The Plan denied your request. The Plan says the services are not a covered benefit under the plan. The Plan states you are responsible for the amount signed before services were rendered and costs as agreed on upon signing treatment plan. The Plan states you are responsible for the denied amount of $4,613.00.
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. The services are not listed in your EOC as a covered benefit; therefore, it is not covered. Therefore, we decided that the Plan does not have to pay for (D0350), (D5820), (D5821), (D1206), (D4999), (D9230) and (D7953) provided.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forhome health services provided to the enrollee on August 6, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plan denied your request. The Plan says the treatment authorization code is missing/invalid.The Plan must follow Medicare rules. Medicare rules say that home health claims require a treatment authorization code.The case file did not contain a valid treatment authorization code. 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 forhome health services provided to the enrollee on August 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an intermittent limb compression device provided to the enrollee July 23, 2019.
You asked the Plan to pay for the intermittent limb compression device. You say that the claim should be paid. The Plan denied your request. The Plan says did not include an itemized shipping/billing invoice to indicate the specific supplies or proof of delivery.
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 proof of delivery for the supplies provided in this case. There is a delivery page itemized for June 11, 2019 which was for the trial of the device. The delivery ticket of the item to the enrollee on July 23, 2019 is not itemized, therefore invalid because it cannot be verified. Therefore, we decided that the Plan does not have to pay for an intermittent limb compression device provided to the enrollee July 23, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthosis (L1833), bilateral wrist hand finger orthosis (L3809) and suspension sleeve (L2397) provided to the enrollee on May 8, 2019.
You asked the Plan to pay for the orthoses and sleeve. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says the services are not supported.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the orthoses and sleeve have not been met. Healthcare Common Procedure Coding System (HCPCS) code L1833-LT-KX (1 Unit) remains not supported. The documentation submitted did not include an itemized shipping/billing invoice to indicate that specific billed supplies were received by the patient. Therefore, the billed supply code cannot be verified. It is noted that multiple attempts were made to contact the provider for additional information. Healthcare Common Procedure Coding System (HCPCS) code L2397-LT-KX (1 Unit) remains not supported. The documentation submitted did not include an itemized shipping/billing invoice to indicate that specific billed supplies were received by the patient. Therefore, the billed supply code cannot be verified. It is noted that multiple attempts were made to contact the provider for additional information.
Healthcare Common Procedure Coding System (HCPCS) code L3809-LT-KX (1 Unit) remains not supported. The documentation submitted did not include an itemized shipping/billing invoice to indicate that specific billed supplies were received by the patient. Therefore, the billed supply code cannot be verified. It is noted that multiple attempts were made to contact the provider for additional information. Healthcare Common Procedure Coding System (HCPCS) code L3809-RT-KX (1 Unit) remains not supported. The documentation submitted did not include an itemized shipping/billing invoice to indicate that specific billed supplies were received by the patient. Therefore, the billed supply code cannot be verified. It is noted that multiple attempts were made to contact the provider for additional information. Therefore, we decided that the Plan does not have to pay for knee orthosis (L1833), bilateral wrist hand finger orthosis (L3809) and suspension sleeve (L2397) provided to the enrollee on May 8, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (an MRI) (70553) and an injection of gadobutrol (A9585) provided by the doctor.
You asked the Plan to waive the copayment for an MRI and an injection. You say that you are appealing the cost share of $50. You say you would like assistance since you are on a limited income and no longer working. The Plan denied your request. The Plan says outpatient diagnostic radiological tests and services have a $50 copayment. The plan benefit says for outpatient radiological diagnostic services performed in a physician's office or free-standing facility (such as a radiology center or medical clinic) there will be a $50 copayment for each covered service.
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 $50 copayment for outpatient diagnostic tests and services. You have been asked to pay a $50 copayment for an MRI and an injection. These services fall within the outpatient diagnostic tests and 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 a magnetic resonance imaging (an MRI) (70553) and an injection of gadobutrol (A9585) provided by the doctor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of pump with oxygenator or heat exchanger (99190) provided.
You asked the Plan to pay for the assembly and operation of pump with oxygenator or heat exchanger. You say that this was a medically necessary service. The Plan denied your request. The Plan says payment of this service is included in the DRG payment.
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 2019 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 pump with oxygenator or heat exchanger (99190) provided.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital discharge day management; more than 30 minutes (CPT Code 99239) provided to the enrollee on April 7, 2019.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 99239 is not supported in the medical record. Specifically, Current Procedural Terminology (CPT) code 99239 (1 Unit) remains not supported. The submitted discharge summary does not support hospital discharge day management of more than 30 minutes was performed. A documented duration of time of 31 minutes or more is required to support this code. Therefore, the billed service cannot be verified. It is noted that multiple attempts were made to contact the provider for additional information. We have insufficient documentation to corroborate the services so we can confirm Medicare coverage has been met. 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 hospital discharge day management; more than 30 minutes (CPT Code 99239) provided to the enrollee on April 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided by out of network provider.
You asked the Plan to pay for physician services. You say that you were never told that the provider was out-of-network. 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 the medical services provided by out of network provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the duplex scan rendered on July 12, 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 93971 is not supported.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 93971 is duplex scan of extremity veins including responses to compression and other maneuvers; unilateral or limited study.We find that CPT code 93971 is not supported in the medical record. Specifically, there is no documentation to support that this procedure was performed. 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 duplex scan rendered on July 12, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (93010) provided July 14, 2019. You asked the Plan to pay for the physician services. You say that services were medically necessary and properly billed.The Plan denied your request. The Plan says the records provided do not support the services billed.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT code 93010 is not supported in the medical record. Specifically, the provided records are limited and were not signed by the rendering physician. Based on this information, we decided that Medicare rules for coverage of the physician services have not been met.Therefore, we decided that the Plan does not have to pay for physician services (93010) provided July 14, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the shingles vaccine you received on August 23, 2019.
You asked the Plan to pay for the shingles vaccine. The Plan denied your request. The Plan says the shingles vaccine is not covered under your medical benefits.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the shingles vaccine. Therefore, we decided that the Plan does not have to pay for the shingles vaccine you received on August 23, 2019.
Benefits for the shingles vaccine 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an initial comprehensive preventive medicine evaluation provided on September 25, 2019.You asked the Plan to pay for preventive exam. You say that this was a primary care physician visit which is covered by your plan with no copayment.The Plan denied your request. The Plan says the denial of payment 
for this service is correct, because this preventive exam is not covered by Medicare or the Plan under any conditions.The Plan must follow Medicare rules. Medicare rules say that routine examinations, including exams without relation to treatment or diagnosis for a specific illness, symptom, complaint, or injury, are not covered by Medicare unless they are explicitly covered by a Medicare statute.We looked at the file and Medicare rules. This exam is not covered by Medicare or the Plan. Based on this information, we decided that Medicare rules for coverage of preventive exam have not been met.Therefore, we decided that the Plan does not have to pay for an initial comprehensive preventive medicine evaluation provided on September 25, 2019