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

We decided that the Plan does not have to pay fora knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on March 8, 2019.You asked the Plan to pay for the orthoses. 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 noncovered visit arelikewise noncovered.Therefore, we decided that the Plan does not have to pay fora knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on March 8, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided thatthe Plan does not have to pay forthe presumptive drug testing, and the definitive drug testing provided on July 9, 2019 by the out of network provider.You asked the Plan to pay forthe laboratory testing. You say that you rely on the referring provider to obtain the necessary authorizations.The Plan denied your request. The Plan says authorization was not obtained before the services was provided to the enrollee. The Plan says the enrollee's primary care physician did not refer them for the services. The Plan also says the services were not urgent or emergent.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 providersonly 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 physician 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 forthe presumptive drug testing, and the definitive drug testing provided on July 9, 2019 by the out of network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy (HIT) services provided from August 5, 2019 to August 12, 2019 billed with code S9328.You asked the Planto pay forthe HIT services. You say that this is a valid code according to the CMS website and should be paid.The Plandenied your request. The Plansaysthis is not a valid code for Medicare billing.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.CPT code S9328 has a status indicator of "I" meaning it is invalid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the HIT services have not been met.Therefore, we decided that the Plandoes not haveto pay forthe home infusion therapy (HIT) services provided from August 5, 2019 to August 12, 2019 billed with code S9328.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9328) provided on September 12, 2019 to September 19, 2019.
You asked the Plan to pay for home infusion therapy. You say that this is a valid code. The Plan denied your request. The Plan says this code is not recognized by Medicare.
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 S9328 is not supported in the medical record. Specifically, this code has a status indicator of "I." Medicare uses another code for reporting of, and payment for these services. Based on this information, we decided that Medicare rules for coverage of home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9328) provided on September 12, 2019 to September 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on June 7, 2019.You asked the Plan to pay for the physician's services. You say that you were unaware that you were out-of-network with the Plan and that is why you did not obtain authorization. The Plan denied your request. The Plan says non-urgent, non-emergent services require prior authorization. The Plan requires utilization of network providers when possible and available.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 these services. Therefore, we decided that the Plan does not have to pay for physician's services provided on June 7, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services provided on July 30, 2019.You asked the Plan to pay for the radiology services. The Plan denied your request. The Plan says there is no valid referral for this 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 did not pre-approve the radiology services. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for radiology services provided on July 30, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the glucose monitor, test strips, lancets, lancet device, and control solution provided by HNC Medical Supplies from May 31, 2019 to August 19, 2019.
You asked the Plan to pay for the glucose monitor (E0607), test strips (A4253), lancets (A4259), lancet device (A4258), and control solution (A4256). 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, lancet device, and control solution provided by HNC Medical Supplies from May 31, 2019 to August 19, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay forthe definitive drug testing for 15-21 drug classes provided on July 24, 2019.You asked the Planto pay forthe definitive drug testing. You say that the testing was ordered by the treating physician and could not be held. This should be covered as medically necessary.The Plandenied your request. The Plansaysthe lab report does not support the billing of 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.We find that CPT code G0482 is not supported in the medical record. Specifically, the lab report does not clearly show that more than 15 drug classes were tested. Based on this information, we decided that Medicare rules for coverage of the definitive drug testing have not beenmet.Therefore, we decided that the Plandoes not haveto pay forthe definitive drug testing for 15-21 drug classes provided on July 24, 2019.
Appeal type: ER
Decision: Favorable

We decided that the Plan has to pay for an emergency department visit (99284) provided on August 4, 2019.You asked the Plan to pay for the emergency department visit. You say that you would like reconsideration as this is not a duplicate claim and the member was seen multiple times on the same date. The Plan denied your request. The Plan says that both emergency visits were essentially for the same reason, therefore only one will be allowed.The Plan must follow Medicare rules. Medicare rules say that if more than one evaluation and management (face-to-face) service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one evaluation and management service may be reported unless the evaluation and management services are for unrelated problems.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the emergency department visit. have been met. Specifically, the record indicates that the two evaluation and management services were provided for unrelated problems. Therefore, we decided that the Plan has to pay for an emergency department visit (99284) provided on August 4, 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for assembly and operation of pump with oxygenator or heat exchanger provided on July 16, 2019.You asked the Plan to pay for assembly and operation of pump with oxygenator or heat exchanger (99190). You say that the Plan should pay this claim.The Plan denied your request. The Plan says Medicare does not pay any provider or supplier other than the hospital for services furnished to the enrollee while an inpatient.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Payment for this service would have been included under the facility claim. Payment to you for this service is the responsibility of the facility or hospital.  Based on this information, we decided that Medicare rules for coverage of assembly and operation of pump with oxygenator or heat exchanger (99190) have not been met.Therefore, we decided that the Plan does not have to pay for assembly and operation of pump with oxygenator or heat exchanger provided on July 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services provided on July 29, 2019 by
the out of network provider.
You asked the Plan to pay for the physician services. The Plan denied your request. The Plan says authorization
was not obtained before the services were provided to the enrollee. The Plan says the enrollee's primary care
physician did not refer them for the services. The Plan also says the services were not urgent or emergent.
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 moderate
sedation services provided on July 29, 2019 by the out of network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the chemotherapy services provided on July 16, 2019.
You asked the Plan to waive the coinsurance for the chemotherapy services. You say that you would like the plan to reconsider your request. The Plan denied your request. The Plan says you received chemotherapy services on the date of service at issue in this appeal. The plan states the correct coinsurance has applied per your contract with the plan.
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 15% coinsurance for Medicare Part B Prescription Drugs. We looked at the file, the Plan contract and Medicare rules. The file shows you received chemotherapy services on July 16, 2109. You have been asked to pay a 15% coinsurance for the chemotherapy services, totaling $640.58. The chemotherapy services fall 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 the chemotherapy services provided on July 16, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the diabetic supplies provided from June 17, 2019 to September 5, 2019.
You asked the Plan to pay for the diabetic supplies. The Plan denied your request. The Plan says that there is no valid 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 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 from June 17, 2019 to September 5, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the abdominal ultrasound provided on April 4, 2019 by the out of network provider.You asked the Plan to pay forthe radiology service. You say that you rely on the hospital personnel to obtain the necessary authorizations.The Plan denied your request. The Plan says authorization was not obtained before the services were provided to the enrollee. The Plan says the enrollee's primary care physician did not refer them for the service. The Plan also says the service was not urgent or emergent.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 forthe abdominal ultrasound provided on April 4, 2019 by the out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 2 periodontal scalings and root planings provided on July 26, 2019.
You asked the Plan to pay for the scalings and planings. You say that you only requested a dental cleaning from this provider. You also say that you were not aware that this provider was performing additional services beyond a cleaning. The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan. The Plan also says that you were informed, prior to the services being rendered, that this service was not covered by the Plan.
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 the 2 periodontal scalings and root planings provided on July 26, 2019.
Your complaint about the provider rendering services you did not request and without informing you is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
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 August 20, 2019 to November 8, 2019.You asked the Plan to pay for the diabetic supplies. The Plan denied your request. The Plan says that valid of 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 itemsat 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 forthe diabetic supplies provided to the enrollee from August 20, 2019 to November 8, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the BLS non-emergency ambulance services provided on
June 28, 2019 by the out of network provider. 
You asked the Plan to pay for the ambulance services. You say that this was a medically necessary transport
reimbursement of this claim in the amount of $0 is not acceptable for ambulance services. The Plan denied
your request. The Plan says enrollees must receive their medical services from an in-network provider. The
plan says that non-emergent services with non-contracted providers require prior-authorization prior to services
being rendered.
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 BLS non-emergency ambulance services
provided on June 28, 2019 by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chondroplasty (29877).
You asked the Plan to pay for the chondroplasty. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the medical records did not include documentation of a surgical knee arthroscopic debridement/shaving of articular cartilage.
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 29877 is arthroscopy, knee, surgical; debridement/shaving of articular cartilage (chondroplasty). We asked our coder 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 chondroplasty. Our reviewer says that CPT code 29877 is not supported. The record states that a synovectomy was performed. Our reviewer found there is no evidence that a chondroplasty was also performed during this episode of care. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the chondroplasty have not been met. Therefore, we decided that the Plan does not have to pay for chondroplasty (29877).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing rendered on June 10, 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 valid physician order.The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 drug testing rendered on June 10, 2019.