Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says care can be received in another setting.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found in the absence of records to review, it is not possible to determine whether or not she meets criteria for an IRF admission. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99214) and an x-ray (72080) provided on July 11, 2019.
You asked the Plan to pay for the office visit and x-ray. You say that you would like reconsideration and are aware this provider does not participate with Medicare. The Plan denied your request. The Plan says Mark Drzala, MD has opted-out of the Medicare program meaning no payment can be made.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by Mark Drzala, MD. This provider has opted out of the Medicare program. The file shows that Mark Drzala, MD entered into a private contract with you regarding payment. Therefore, we decided that the Plan does not have to pay for an office visit (99214) and an x-ray (72080) provided on July 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for blood glucose/reagent strips (A4253) lancets (A4259) calibrator solutions/chips (A4266) lithium battery for blood glucose monitor (A4235) provided from August 2, 2019 to October 21, 2019.
You asked the Plan to pay for the diabetic supplies. You say that that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says the documentation does not support the supplies billed.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The proof of delivery did not include an order number or details to corroborate the delivery ticket submitted. The delivery ticket submitted did not include the carrier's tracking number. 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. Therefore, we decided that the Plan does not have to pay for blood glucose/reagent strips (A4253) lancets (A4259) calibrator solutions/chips (A4266) lithium battery for blood glucose monitor (A4235) provided from August 2, 2019 to October 21, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an injection provided on July 8, 2019.
You asked the Plan to waive the coinsurance for an injection. You say that you were told that your copayment would be $5. You say that you would like these charges dropped. The Plan denied your request. The Plan says the correct coinsurance has been applied.
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% coinsurance for Medicare Part B prescription drugs. You have been asked to pay a 20% coinsurance of the allowed amount for an injection. The allowed amount is $6,039.30. The total amount you are being asked to pay is $1,207.86 ($6,039.30 x 20% = $1,207.86). The correct coinsurance has been applied for the injection that was provided. An injection falls within the Medicare Part B prescription drugs 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 an injection provided on July 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for water circulating cold pad with pump (E0218) provided on June 11, 2019.
You asked the Plan to pay for water circulating cold pad with pump. You say that the hospital considered the ice machine an expendable item and it was sent home with you. You needed it at home on a continuous basis for weeks to continue reducing the swelling and extreme pain. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of water circulating cold pad with pump have not been met. Therefore, we decided that the Plan does not have to pay for water circulating cold pad with pump (E0218) provided by MDS Medical Device June 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for office visits provided from June 14, 2019 to October 21, 2019.
You asked the Plan to waive the copayments for office visits. You say that these were follow-up visits and 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 $10 copayment for physician/practitioner services, including doctor's office visits. You had office visits from June 14, 2019 to October 21, 2019 for a total of 3 visits. Therefore, you are responsible to pay a $10 copayment per each visit. The total amount you owe is: $30.00. You have been asked to pay the total copayment amount of $30.00 for office visits. Office visits fall 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 copayments for office visits provided from June 14, 2019 to October 21, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a wrist-hand orthosis (L3916) provided to the enrollee on March 1, 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 documentation does not indicate services are necessary for treatment of the enrollee's condition.
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 a wrist-hand orthosis (L3916) provided to the enrollee on March 1, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthosis (L1851) suspension sleeve (L2397) provided on January 25, 2019.
You asked the Plan to pay for the orthoses. You say that please see the attached medical records and process the claim for payment. The Plan denied your request. The Plan says there is insufficient documentation to corroborate the service to confirm that Medicare coverage criteria has been met.
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 noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for knee orthosis (L1851) suspension sleeve (L2397) provided on January 25, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 30, 2019 by an out of network provider.
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 were rendered by a non-network provider without 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 has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on July 30, 2019 by the out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for test strips, lancets, control solution, and batteries provided from July 20, 2019 to October 8, 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 billed supply codes cannot be verified.
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, lancets, control solution, and batteries provided from July 20, 2019 to October 8, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of an interlaminar/interspinous process stabilization/distraction device (22869 and 22870).
You asked the Plan to pre-approve the device. You say that there is significant clinical and diagnostic patient specific data which supports medical necessity. The Plan denied your request. The Plan says the device has not been appropriately studied and is not indicated for use in the treatment of the member's condition.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are 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 pre-approve the device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device remains experimental and more research is needed. 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of an interlaminar/interspinous process stabilization/distraction device (22869 and 22870).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chronic care management services provided on August 31, 2019 by an out of network provider.
You asked the Plan to pay for the chronic care management services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.
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 chronic care management services provided on August 31, 2019 by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for moderate sedation services (99153) provided on August 23, 2019.
You asked the Plan to pay for the moderate sedation services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says payment for 99153 is included in the payment to the facility and not separately reimbursable.
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 99153 is not supported in the medical record. Specifically, 99153 is a "technical only" code and Medicare considers that the independent trained observer represents an expense to the facility. Based on this information, we decided that Medicare rules for coverage of the moderate sedation services have not been met. Therefore, we decided that the Plan does not have to pay for moderate sedation services (99153) provided on August 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 29, 2019 by an out of network provider.
You asked the Plan to pay for the office visit. You say that you are appealing with records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and the enrollee self-directed for service.
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 August 29, 2019 by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuation of care with your provider.
You asked the Plan to pre-approve a continuation of care with your provider. You say that you have been a patient with this provider for the past five years. The Plan denied your request. The Plan says this physician group has decided to not continue care for your plan's members.
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. Your provider is not a network provider with the Plan. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a continuation of care with your provider. Our reviewer says that the criteria for out-of-network coverage have not been met. Our physician reviewer found the enrollee has a history of multiple sclerosis and has been treated with Copaxone. Our physician reviewer found that the medical records provided suggest that the enrollee's MS has otherwise been clinically stable. Our physician reviewer found that the enrollee has been on Copaxone for an extended period of time. Our physician reviewer found that the enrollee's care can be safely and effectively transitioned to an in-network provider without consequence or harm to his health and condition. Our physician reviewer found that, given the stability of the enrollee's disease, ongoing management would be straight forward at this time and can be readily handled by an in-network neurologist. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a continuation of care with your provider have not been met. 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 a continuation of care with your provider. Therefore, we decided that the Plan does not have to pre-approve a continuation of care with this provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for assistant at surgery services provided on July 31, 2019.
You asked the Plan to pay for assistant at surgery services. You say that you are appealing with the operative report. The Plan denied your request. The Plan says the denial of payment for these services is correct, because the documentation submitted does not support why an assistant was necessary for these surgical procedures.
The Plan follows Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Medicare rules say that for procedures with an assistant surgery indicator of 0, the payment restriction for assistants at surgery applies to this procedure unless supporting documentation is submitted to establish medical necessity. In this case, you billed assistant surgery services for CPT codes 15002 and 15003. The Medicare Fee Schedule Database contains a surgical indicator of 0 for these procedures. We looked at this the file and Medicare rules. The documentation submitted does not support the need for an assistant at surgery for these services. Based on this information, we decided that Medicare rules for coverage of assistant at surgery services have not been met. Therefore, we decided that the Plan does not have to pay for assistant at surgery services provided on July 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on May 29, 2019 by an 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 for these services. The Plan says that your doctor is an out-of-network provider as well.
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 May 29, 2019 by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hot or cold pack therapy (97010), mechanical traction therapy (97012), manipulative treatment (98941) and electrical stimulation (G0283) provided on April 25, 2019 through July 15, 2019.
You asked the Plan to pay for the chiropractic services. You say that you would like reconsideration as you have been seeing this provider for chiropractic treatment and would like to remain under their care. The Plan denied your request. The Plan says the manipulation services (98941) were received out-of-network and you do not have out-of-network benefits. The remaining services were denied because they are not covered services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. Additionally, the rules say that the only chiropractic service Medicare covers is manual manipulation of the spine. 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. Additionally, the hot or cold pack therapy, mechanical traction therapy and electric stimulation are not covered benefits.
Therefore, we decided that the Plan does not have to pay for hot or cold pack therapy (97010), mechanical traction therapy (97012), manipulative treatment (98941) and electrical stimulation (G0283) provided on April 25, 2019 through July 15, 2019.