Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora shoulder arthroscopy (29823) provided on July 30, 2019.You asked the Plan to pay forthe shoulder arthroscopy. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the operative report did not include sufficient documentation to meet the guidelines of a surgical shoulder arthroscopy with extensive debridement.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 29823 is arthroscopy, shoulder, surgical; debridement, extensive.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 shoulder arthroscopy. Our reviewer says that CPTcode 29823 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical record submitted does not indicate the degree of debridement performed, therefore, it is inappropriate to bill CPT code 29823 to represent the services performed on July 30, 2019.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 shoulder arthroscopy have not been met.Therefore, we decided that the Plan does not have to pay fora shoulder arthroscopy (29823) provided on July 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chiropractic services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve chiropractic services. You say that you have established care with this doctor. You say that you would like to continue seeing him. The Plan denied your request. The Plan says the requested doctor is out-of-network. The Plan says that there are in-network providers available for these 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 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. 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve chiropractic services to be provided by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the observation stay provided from September 20, 2019 through September 21, 2019.
You asked the Plan to waive the coinsurance for the observation stay. You say that you went to the emergency department. You say that you should not be charged this much when you were not in the hospital. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for each outpatient hospital and observation service.
You have been asked to pay $548.01, which is 20% of the allowed amount for the observation stay. The allowed amount is $2,740.05 (20% x $2,740.05 = $548.01). The observation stay falls within the "Outpatient hospital services" benefit category. The records show that you were in outpatient observation. 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 observation stay provided from September 20, 2019 through September 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on November 19, 2018.
You asked the Plan to waive the copayment for the specialist office visit. You say that you were told this was covered and not told of the charges for a specialist consult. 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 $45 copayment for each in-network Medicare-covered visit with a specialist, after your yearly deductible is met. You have been asked to pay a $45 copayment for the specialist office visit. The specialist office visit falls 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 copayment for the specialist office visit provided on November 19, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve an office visit. You say that your doctor referred you to see this doctor. The Plan denied your request. The Plan says this provider is not in-network. The Plan says that there are in-network providers available to provide these 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 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. 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve an office visit to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthosis (L1833) suspension sleeve (L2397) lumbar-sacral orthosis (L0650) provided October 1, 2019.
You asked the Plan to pay for the orthoses. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says there is no evidence of an established relationship between the enrollee and the ordering physician, there was no claims submitted for an evaluation and management service and there is no evidence of a prior telehealth service with the ordering physician as required per CMS guidelines.
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 knee orthosis (L1833) suspension sleeve (L2397) lumbar-sacral orthosis (L0650) provided October 1, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an angiogram and related services (37244, 36247, 75774, 75726) 
You asked the Plan to pay for the radiology services. You say that services were medically necessary. The Plan denied your request. The Plan says insufficient medical records were provided to make a determination.
The Plan must follow Medicare rules. Medicare rules say that providers must furnish the carrier with sufficient documentation to support claims submitted. We looked at the file and Medicare rules. Only one page of medical records was submitted by the provider. There is insufficient documentation for a determination of medical necessity to be made. Based on this information, we decided that Medicare rules for coverage of the radiology services have not been met. Therefore, we decided that the Plan does not have to pay for an angiogram and related services (37244, 36247, 75774, 75726)
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a duplex scan (93880) provided on September 3, 2019.
You asked the Plan to waive the copayment for a duplex scan. You say that you went to the hospital on September 3, 2019 for pre-op testing. All the testing was done there and you did not leave or go to a separate specialist's office. You received a second bill for the same series of testing. You do not feel you should be billed separately for these services (extra-cranial study, vascular study, extremity studies) when it was part of the pre-op testing and services were rendered in the same facility. I am requesting that the Plan waive my $30 liability for this claim. The Plan denied your request. The Plan says other Medicare-covered outpatient diagnostic tests have a $30 copayment when provided by a specialist.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $30 copayment for other Medicare-covered outpatient diagnostic tests. The enrollee has been asked to pay a $30 copayment for a duplex scan. This service falls within the other Medicare-covered outpatient diagnostic tests benefit category. The record shows that services were rendered to you by a specialist. This means that you have been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a duplex scan (93880) provided on September 3, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the physical therapy visits provided from
September 5, 2019 to September 26, 2019.
You asked the Plan to waive the copayments for the physical therapy visits. You say that you were told by the
physical therapy office that you did not have a copayment for your visits. 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 $40
copayment for in-network Medicare-covered physical therapy services.
You have been asked to pay a $40 copayment for each of the physical therapy visits. ($40 x 7 visits = $280).
The physical therapy visits fall within the "Outpatient rehabilitation 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 copayments for the physical therapy visits provided from September 5, 2019 to
September 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that custom foot orthotics are necessary due to your shorter right leg, arthritis and severe foot pain. The Plan denied your request. The Plan says this item is not a covered benefit.
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. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 1 power mobility device.
You asked the Plan to pre-approve a Group 1 power mobility device. You say that you can walk about 30-40 feet and then have trouble breathing. The Plan denied your request. The Plan says the report shows you can walk without the use of assistive devices and a walker with seat may help you inside your home.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The file shows that you do not have a mobility deficit that impairs your participation in MRADLs, your condition can be improved by a walker, and you cannot safely operate the PMD being requested in your home. The assessment shows your home cannot accept any type of scooter. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 1 power mobility device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for64 percutaneous tests with allergenic extracts (95004) provided on October 5, 2019.You asked the Plan to pay for64 percutaneous tests with allergenic extracts. You say that this should be reprocessed.The Plan denied your request. The Plan says his code is not supported by the records.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 95004 is percutaneous tests (scratch, puncture, prick) with allergenic extracts, immediate type reaction, including test interpretation and report, specify number of tests.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 64 percutaneous tests with allergenic extracts. Our reviewer says that 64 units of CPT 95004 are not supported. Our physician reviewer found while the office note purports that allergy skin testing was performed, clear documentation of the testing and the number of items tested has not been submitted for review.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 64 percutaneous tests with allergenic extracts have not been met.Therefore, we decided that the Plan does not have to pay for64 percutaneous tests with allergenic extracts (95004) provided on October 5, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Go-Go Elite Traveler 3-wheel scooter.
You asked the Plan to pre-approve a Group 1 power operated vehicle. You say that you want a Group 1 power operated vehicle to get around, partake in family activities, and have independence and mobility. The Plan denied your request. The Plan says your physical therapy notes indicate you are able to complete MRADLs and there is no face-to-face documentation from your physician. The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The documentation submitted is not a valid face-to-face encounter. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a Go-Go Elite Traveler 3-wheel scooter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forBedside drainage bag (A4357) provided October 25, 2019.You asked the Plan to pay forBedside drainage bag. You say that you're submitting reconsideration with supporting documents. Please review.The Plan denied your request. The Plan says billed without the modifier KX. Per CMS guidelines, Modifier KX is required to validate that medical necessity has been met.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 A4357 was billed without the modifier. Based on this information, we decided that Medicare rules for coverage of Bedside drainage bag have not been met.Therefore, we decided that the Plan does not have to pay forBedside drainage bag (A4357) provided October 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean oxygen concentrator and portable gaseous oxygen system.You asked the Plan to pre-approvean oxygen concentrator and portable gaseous oxygen system. You say that the enrollee needs an oxygen concentrator and portable gaseous oxygen system.The Plan denied your request. The Plan says medical records show the enrollee does not have low oxygen levels on room air.The Plan must follow Medicare rules. The rules say that for patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90%, there is a rebuttable presumption of non-coverage for home oxygen.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an oxygen concentrator and portable gaseous oxygen system have not been met.Therefore, we decided that the Plan does not have to pre-approvean oxygen concentrator and portable gaseous oxygen system.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on September 24, 2019.
You asked the Plan to pay for the pump operation and assembly. You say that it takes a half hour to set up the 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 payment for this service is the responsibility of the facility to any vendor.
The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the pump operation and assembly have not been met. Specifically, the payment for this service is included in the DRG payment to the facility. Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on September 24, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for Inpatient Hospital care provided October 5, 2018 to October 9, 2018 
You asked the Plan to pay for the inpatient services. You say that the services were medically necessary. The Plan denied your request. The Plan says no medical records were received to verify if the services were medically necessary. The services were rendered out-of-network and no preauthorization was received.
The Plan must follow Medicare rules. Medicare rules say that providers must furnish the carrier with sufficient documentation to determine payment. We looked at the file and Medicare rules. No medical records were provided to the plan for the dates of service at issue. Based on this information, we decided that Medicare rules for coverage of the inpatient services have not been met. Therefore, we decided that the Plan does not have to pay for Inpatient Hospital care provided October 5, 2018 to October 9, 2018
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services to be provided by an out of network provider.
You asked the Plan to pre-approve the physician's services. You say that you have been under the care of this physician for 12 years and you would like coverage from the Plan to continue seeing her. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
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. 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. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physician's services to be provided by the out of network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from June 3, 2019 to July 2, 2019.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee did not require any additional skilled services that could not have been provided in an alternate setting other than a SNF.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 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 skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from June 3, 2019 to July 2, 2019.