Persius/hicric huggingface dataset:
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the echocardiography provided on October 3, 2019. 
 
You asked the Plan to pay for the echocardiography. You say that this claim was not related to hospice. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on October 2, 2019. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the echocardiography provided on October 3, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ER visit provided from November 17, 2019 through November 19, 2019. 
 
You asked the Plan to waive the copayment for the ER visit. You say that Medicaid should cover the copayment. The Plan denied your request. The Plan says the copayment applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay an $80 copayment for Medicare-covered emergency room visits. 
 
You have been asked to pay an $80 copayment for the ER visit. The ER visit falls within the "Emergency care" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ER visit provided from November 17, 2019 through November 19, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from November 2, 2019 to November 26, 2019.
You asked the Plan to pay for home health services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are missing required information.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the claim was submitted with an incorrect/invalid FIPS code. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from November 2, 2019 to November 26, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional problem focused limited oral evaluation and resin-based composite provided on November 15, 2019 and December 12, 2019. 
 
You asked the Plan to pay for the additional problem focused limited oral evaluation, and additional resinbased composite. You say that when you went to your dentist you were advised that your exams and fillings were covered. The Plan denied your request. The Plan says your plan benefits do not provide coverage for a problem focused limited oral evaluation. The Plan also says that the benefits for the resin-based composite had been satisfied and the frequency limitation had been exceeded. 
 
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, exams and restorations are each limited to two procedures per calendar year. The record shows that you received an exam on August 9, 2019 and November 15, 2019 and your exams benefit was then exhausted. The record also shows that you received resin-based composites on November 15, 2019 and December 12, 2019 and your restorations benefit was then exhausted. Therefore, we decided that the Plan does not have to pay for the additional problem focused limited oral evaluation and resin-based composite provided on November 15, 2019 and December 12, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the GeneSight Psychotropic Assay rendered on September 26, 2019. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that GeneSight testing is covered when specific criteria are met. 
 
We looked at the file and Medicare rules. There is no documentation to support that the testing meets the criteria for coverage for this enrollee. 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 GeneSight Psychotropic Assay rendered on September 26, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray coded 71045 provided on October 25, 2019. 
 
You asked the Plan to pay for the x-ray. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not separately payable. 
 
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, we have confirmed that code 71045 for the x-ray has a bundled relationship with code 32555 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the x-ray coded 71045 provided on October 25, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the ambulance transport provided on October 10, 2019.
You asked the Plan to waive the copay for the ambulance transport. You say that you shouldn't have to pay because your family could have transported you. The Plan denied your request. The Plan says the copay was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 copay for each day (one-way or round trip) for Medicare-covered ambulance services. You have been asked to pay a $150 copay for the ambulance transport. The ambulance transport falls within the each day (one-way or round trip) for Medicare-covered ambulance 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 copay for the ambulance transport provided on October 10, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a colonoscopy provided on March 8, 2019. 
 
You asked the Plan to waive the copayment for a colonoscopy. You say that you were never informed of the charges and disagree. 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 $50 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers.  
 
You have been asked to pay a $50 copayment for a colonoscopy. A colonoscopy falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 colonoscopy provided on March 8, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided January 22 to January 28, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient level services were medically necessary. The Plan denied your request. The Plan says that rules for coverage were not met. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 
 
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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the records show the inpatient level care was medically necessary. The attending physician could reasonably expect that inpatient care would be required for more than two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided January 22 to January 28, 2020.  
 
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 99190) provided on November 12, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment for this
service is included in the Part A DRG payment to the facility.
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other
than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all
necessary covered services to the beneficiary either directly or under arrangements made with outside
providers. Payment for all fees related to this service would have been included under the facility claim.
Therefore, we decided that the Plan does not have to pay for the services (CPT 99190) provided on November
12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 13, 2019 to January 22, 2020 by an out of network (OON) 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 an out-of-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 August 13, 2019 to January 22, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an MRI of the abdomen. 
 
You asked the Plan to pre-approve an MRI of the abdomen. You say that the requested MRI of the abdomen is medically necessary. The Plan denied your request. The Plan says the requested MRI of the abdomen is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary.  
 
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 an MRI of the abdomen. Our reviewer says that the requested MRI of the abdomen is not medically necessary. Our physician reviewer found the enrollee is with a history of hypertension, diabetes and an umbilical hernia. Based on the provided medical records he has had three surgeries for the umbilical hernia - in 1974, 1996 and in 2003. There are no reports of nausea, anorexia, vomiting or diarrhea. There is a report of "positive abdominal pain or blood" with no further details given. The documented physical examinations report no abnormal findings. A CT scan of his abdomen was done on 12/13/2017 which showed a hiatal hernia, diastasis recti and no other acute findings. There is no report of any mass or tumor of malignancy. He has reportedly had "abdominal concerns" and an MRI scan of the abdomen was ordered on 03/02/2020. Based on the medical records provided the MRI scan of the abdomen is not medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an MRI of the abdomen have not been met. Therefore, we decided that the Plan does not have to pre-approve an MRI of the abdomen
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on December 27, 2019. 
 
You asked the Plan to pay for the lumbar-sacral orthosis (L0650). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the documentation submitted did not indicate the provider discussed the need for the billed supply codes, therefore the billed supply codes cannot be verified. 
 
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. No medical records were received to support the diagnosis on the submitted order, therefore the billed codes cannot be supported. Based on this information, we decided that Medicare rules for coverage of the lumbar-sacral orthosis (L0650) have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on December 27, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on November 5, 2019 by an out of network (OON) 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 an out-of-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 laboratory services provided on November 5, 2019 by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on
January 5, 2020.
You asked the Plan to waive the copayment for the emergency room visit. You say that you should not be
charged the emergency room copayment because all they did was wash out your eye. You say they should not
be able to charge that amount. The Plan denied your request. The Plan says you have been charged the correct
cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90
copayment per emergency department visit.
You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls
within the "Emergency care" benefit category. The medical record shows you received services during your
emergency room visit.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that
the Plan does not have to waive the copayment for the emergency room visit provided on January 5, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the paramedic intercept, rural area (A0432) provided December 1, 2019. 
 
You asked the Plan to pay for the paramedic intercept. You say that you provided an additional paramedic to ride on board the transporting BLS ambulance. You are only allowed to charge for the services provided which is the paramedic intercept charge. The Plan denied your request. The Plan says resubmit with other CPT/HCPCS code. The HCPCS code must be used to reflect the type of service the beneficiary received not the type of vehicle used. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by an emergency medical technician (EMT) intermediate or EMTParamedic only in certain circumstances. Medicare allows ALS paramedic intercept services only when the services are furnished under a contract with a qualified basic life support (BLS), the provision of medically necessary supplies and services, with a volunteer ambulance company. In addition, State law must not allow the volunteer ambulance company to bill for the transport or BLS services.  
 
The Plan has confirmed that this provider  does not have a contract with the volunteer ambulance company that provided the transport services. Therefore, we decided that the Plan does not have to pay for the paramedic intercept, rural area (A0432) provided December 1, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the ankle foot orthoses and heel stabilizers provided by on August 19, 2019. Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. 
 
You asked the Plan to pay for the ankle foot orthoses (L1971) and heel stabilizers (L3170). You say that the orthoses were medically necessary. The Plan denied your request. The Plan says rules for telehealth services were not met. 
 
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 ankle foot orthoses (L1971) and heel stabilizers (L3170). Our reviewer says that the ankle foot orthoses are not medically necessary. Our physician reviewer found based on the documentation provided the health plan's denial should be upheld. The enrollee is reported to have bilateral knee pain and left wrist pain.  No detailed history, recent injury or surgery, associated symptoms, review of systems or physical examination, including weakness and/or deformity, of the affected areas has been documented.  There is no evidence of diagnostic evaluation (i.e. x-rays) or prescription therapy provision/response (i.e. prescription meds, injections, PT/OT).  Therefore, the documentation does not support the medical necessity or reasonableness of the provided service. 
 
We looked at this physician's review, the file, and Medicare rules. Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. Although orthotics may be appropriate, neither Medicare nor the Plan provides coverage of heel stabilizers for the enrollee's condition. Based on this information, we decided that Medicare rules for coverage of the ankle foot orthoses (L1971) and heel stabilizers (L3170) have not been met. Therefore, we decided that the Plan does not have to pay for the ankle foot orthoses and heel stabilizers provided on August 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient services provided on November 21, 2019 by an out of network (OON) provider.
You asked the Plan to pay for outpatient services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says the referring provider is out-of-network. The Plan says that 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 outpatient services provided on November 21, 2019 by an out of network (OON) provider.