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

We decided that the Plan does not have to pay for the lab testing provided on August 23, 2019.You asked the Plan to pay for the lab testing. The Plan denied your request. The Plan says screening tests are not covered.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.The tests at issue in this appeal, the lab services, were requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes.Therefore, we decided that the Plan does not have to pay for the lab testing provided on August 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe discharge services (CPT 99239) provided to the enrollee on October 27, 2018.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the billed service cannot be verified.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 99239 is "Hospital discharge day management; more than 30 minutes".We find that CPT code 99239 is not supported in the medical record. Specifically,the records provided do not support that more than 30 minutes of discharge day management services were provided on the date of service in question. 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 forthe discharge services (CPT 99239) provided to the enrollee on October 27, 2018
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided by an out-of-network provider from June 17, 2019, to July 15, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the services were not authorized.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 services at issue in this appeal. 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 forthe medical services provided by an out-of-network provider from June 17, 2019, to July 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9328) provided on August 19, 2019 through August 26, 2019.You asked the Plan to pay for the home infusion therapy. You say that S9328 is a valid code per CMS.The Plan denied your request. The Plan says S9328 is not valid for Medicare purposes.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT code S9328is not supported in the record. Specifically, per the 2019 Physician Fee Schedule, S9328 has a status code of "I." This means that S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the 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 August 19, 2019 through August 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the injections, comprehensive metabolic panel, complete blood count, and chemotherapy administration provided on July 16, 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 rendered to the enrollee. The Plan says the enrollee was referred by another out of network provider. 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 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 injections, comprehensive metabolic panel, complete blood count, and chemotherapy administration provided on July 16, 2019 by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on June 25, 2019 by out of network provider.You asked the Plan to pay for physician services. You say that since the member was in a nursing facility, the doctor is not responsible to get authorization.The Plan denied your request. The Plan says since prior authorization was not obtained the claim has been correctly denied for payment.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. The nursing facility, the referring provider, is also out-of-network. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay for the medical services provided on June 25, 2019 by out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for assembly and operation of pump with oxygenator or heat exchanger (99190) provided on July 29, 2019 You asked the Plan to pay for assembly and operation of the heart lung machine. You say that it takes a half hour to an hour  to set up the heart lung machine and the perfusionist is required to be in the operating room during the length of the procedure.The Plan denied your request. The Plan says the services are a Part A benefit while an inpatient hospital admission and are included in the facility DRG payment.The plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility 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. You provided perfusionist services to the enrollee while inpatient in a hospital. Payment for this service would have been included under the facility claim for the inpatient hospital admission.Payment to you for this service is the responsibility of the facility or hospital. Therefore, the plan is not required to pay you separately for this claim. Based on this information, we decided that the Plan does not have to pay for assembly and operation of pump with oxygenator or heat exchanger (99190) provided July 29, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance mileage (A0425) provided on March 22, 2019.You asked the Plan to pay for the ambulance mileage. You say that the ALS emergency transport was covered and paid for and you need to know why the mileage for the ambulance service is not covered.The Plan denied your request. The Plan says the modifier origin and destination combinations of HP (hospital to physician's office) are not covered and excluded from payment.The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when they meet certain origin and destination requirements. A doctor's office is not a covered destination. The services you have asked the Plan to pay for are ambulance transport services to a doctor's office.Therefore, we decided that the Plan does not have to pay for the ambulance mileage (A0425) provided on March 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the medical office visits provided by from September 5, 2019 to September 20, 2019.You asked the Plan to waive the copayments for the medical office visits. You say that you should not be responsible for the copayments. 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 $45 copayment for each in-network Medicare covered visit. You have been asked to pay $45 copayment for each of the medical eye exams. The medical office visits fall within the each "Vision care" benefit category. The record shows you had diagnoses of trichiasis and other corneal dystrophies which make the visits medical in nature.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 medical office visits provided from September 5, 2019 to September 20, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency department (ED) visits (99283, 99282) provided from July 3, 2019 to August 11, 2019.You asked the Plan to waive the copayment for the ED visits. You say that you should not be responsible for the copayments based on the service you received.The Plan denied your request. The Plan says based on Medicare billing criteria, the claims were billed 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 $75 copayment for emergency care. You have been asked to pay $150 for the ED visits. $75 per ED visit (x2) equals $150. An ED 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 emergency department (ED) visits (99283, 99282) provided from July 3, 2019 to August 11, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction of an erupted tooth or exposed root (D7140) for teeth # 18 and 31 provided on August 7, 2019.You asked the Plan to pay for the dental services. You say that you were inpatient in the hospital due to clostridium difficile (C-diff). You say that you were advised you needed teeth pulled. You also say that the services were done while you were inpatient due to the antibiotics you were already on.The Plan denied your request. The Plan says the dental plan only covers preventive dental service. The Plan says that extractions are not a preventive service and therefore are not covered.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 extractions are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe extraction of an erupted tooth or exposed root (D7140) for teeth # 18 and 31 provided on August 7, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the walker provided  on June 15, 2019.
You asked the Plan to waive the coinsurance for the walker. You say that you were told you were entitled to one piece of equipment to aid in your recovery without any charge. The Plan denied your request. The Plan says you were charged this cost share 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 20% coinsurance for durable medical equipment and related supplies. You have been asked to pay 20% coinsurance for the walker. The walker falls within the durable medical equipment and related supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the cost share for the walker provided on June 15, 2019.
Appeal type: ER
Decision: Favorable

We decided that the Plan has to pay for emergency care services provided on August 23, 2018.You asked the Plan to pay for emergency care services. You say that you are appealing with records.The Plan denied your request. The Plan says that the denial of payment for these services is correct, because a corrected claim must be sent for payment to be considered.The Plan must follow Medicare rules. The rules say that an emergency exists based on a prudent layperson standard, not a retrospective medical review. For symptoms to be considered emergent in nature, they must be such that a prudent layperson with an average knowledge of medicine would reasonably expect the absence of immediate medical attention would result in serious jeopardy to their health. We decided that this case does meet prudent layperson criteria for emergency care. A prudent layperson with an average knowledge of medicine would reasonably expect the absence of immediate medical care to seriously jeopardize their health in this case.Therefore, we decided that the Plan has to pay for emergency care services provided on August 23, 2018.
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 podiatry services. You say that you would like this claim reprocessed and paid. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora remote evaluation of single, dual, or multiple lead pacemaker system with a qualified health care professional (93294, 93296) provided on July 25, 2019 by an out of network provider.You asked the Plan to pay fora remote evaluation of single, dual, or multiple lead pacemaker system with a qualified health care professional. You say that you are appealing claim payment denial for services rendered to your member on date of service July 25, 2019.The Plan denied your request. The Plan says prior authorization was not obtained by the provider or facility. The provider should have verified the member's eligibility, health benefits and obtained authorization prior to the member's visit before providing services to the member as outlined on the member's ID card. The Plan also says that non-emergent services rendered by non-participating providers in non-participating facilities require prior authorization as outlined in the enrollee's 2019 EOC.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 Planto pay for these items/services.Therefore, we decided that the Plan does not have to pay fora remote evaluation of single, dual, or multiple lead pacemaker system with a qualified health care professional (93294, 93296) provided on July 25, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a visual field examination provided on August 16, 2019.You asked the Plan to pay for the visual field examination. The Plan denied your request. The Plan says an extended eye exam is not a covered benefit.Medicare generally does not cover routine vision services. However, the Plan offers a routine vision benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.We looked at the file and the Plan's rules. The file shows that the Plan covers one routine eye exam every year. Therefore, we decided that the Plan does not have to pay for a visual field examination provided on August 16, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for 3 units of a therapeutic procedure (97112) provided on July 29, 2019 through July 31, 2019.
You asked the Plan to pay for 3 units of a therapeutic procedure. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the units 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. In this case, the CPT Code Manual definition of code 97112 is 3 units of a therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities 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 3 units of a therapeutic procedure. Our reviewer says that 3 units of CPT code 97112 is not supported on the dates in question. Our reviewer found the medical record states that 25 minutes were spent performing therapeutic neuromuscular reeducation exercises. According to CPT rules, this equals 2 units of CPT code 97112. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of 3 units of a therapeutic procedure have not been met. Therefore, we decided that the Plan does not have to pay for 3 units of a therapeutic procedure (97112) provided on July 29, 2019 through July 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an office visit on July 3, 2019.You asked the Plan to waive the deductible for an office visit. You say that you disagree with the out-of-network 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. Your contract with the Plan says that there is a $750 deductible for out-of-network physician/practitioner services, including doctor's office visits. You had an office visit with an out-of-network provider on July 3, 2019. Therefore, you are responsible to pay the allowed amount of $203.57, which is applies to the $750 deductible. The item or service you asked the Plan to waive the deductible for falls within the benefit category physician/practitioner services, including doctor's office visits. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible for out-of-network services physician/practitioner services, including doctor's office visits. This cost sharing is a contractual obligation that had not been met at the time an office visit was received on July 3, 2019.Therefore, we decided that the Plan does not have to waive the deductible for an office visit on July 3, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the MRI provided on June 6, 2019.You asked the Plan to waive the copayment for the MRI. You say that the Plan pays more for regular x-rays. You say that you are not able to pay this.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 a $180 copayment for in-network advanced imaging services. You have been asked to pay a $180 copayment for the MRI. The MRI falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the MRI provided on June 6, 2019.