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

We decided that the Plan does not have to pay for the air ambulance transportation (A0435 and A0430)

You asked the Plan to pay for the air ambulance transportation. You say that you would like reconsideration
because it was necessary for the member to be transferred in order to receive proper medical care. The Plan
denied your request. The Plan says the information provided indicated that the member could have been treated
at the initial facility, therefore transport was not medically required.
The Plan follows Medicare rules. The rules say that coverage is not available for transport from a hospital
capable of treating the patient because the patient and/or the patient's family prefer a specific hospital or
physician.
We looked at your request, the file, and Medicare rules. Based on this information, we decided that Medicare
rules for coverage of the air ambulance transportation have not been met. Specifically, the record indicates that
this transfer was requested due to family preference. Necessary care could have been rendered in the initial
facility. Therefore, we decided that the Plan does not have to pay for the air ambulance transportation (A0435
and A0430)
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for wrist hand orthosis (L3916) provided.
You asked the Plan to pay for the orthosis. You say that please see the attached medical records which prove
the medical necessity of the item and process the claim for payment. The Plan denied your request. The Plan
says the records provided do not support the service billed.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for the orthosis. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found an appropriate history and a physical examination of the wrist would reasonably be required to
adequately assess whether the wrist/hand orthosis was medically reasonable and necessary. The documentation
does not support that the wrist/hand orthosis was medically reasonable and necessary in this case, as there is
insufficient documentation of a physical examination of the wrist. The documentation in the case file does not
support that the requested wrist/hand orthosis was medically reasonable and necessary for the enrollee in this
case.
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 orthosis have not been met. Therefore, we decided that the Plan does not
have to pay for wrist hand orthosis (L3916) provided.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient behavioral health services provided from January
11, 2019 to January 26, 2019 by the appealing provider.
You asked the Plan to pay for the inpatient behavioral health services. You say that the services were provided
and payment should be rendered. The Plan denied your request. The Plan says a provider must be enrolled in
the Medicare program for payment to be made. Therefore, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for
services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare
program.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the inpatient behavioral health services have not been met. Specifically, the record shows that the
provider was not enrolled in the Medicare program for the dates of service at issue. Therefore, we decided that
the Plan does not have to pay for inpatient behavioral health services provided from January 11, 2019 to
January 26, 2019 by the appealing provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on December 11, 2019.You asked the Plan to waive the copayment for the office visit. You say that the doctor didn't provide treatment.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 $40 copayment per visit for an in-network specialist office visit. You have been asked to pay a $40 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show that you were examined and recommendations were provided. 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 office visit provided on December 11, 2019
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.You asked the Plan to pre-approve SNF care. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.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 pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the provided medical records do not indicate a need for daily skilled services or inpatient services. Based on the medical records provided there is concern that you would not be able to fully participate in and benefit from daily skilled therapy services.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met.Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient labwork provided on October 14, 2019 by an out of network (OON) provider.You asked the Plan to pay for outpatient lab work. You say that the patient had active coverage on the date of service and shouldn't be held liable for any charges except for contractual obligations.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 lab work provided on October 14, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services (98940, 97140, 97110, 97014) provided by an out of network (OON) provider.
You asked the Plan to pay for OON chiropractic services. You say that you were told this provider was in-network. The Plan denied your request. The Plan says these 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 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 chiropractic services (98940, 97140, 97110, 97014) 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 a continuous glucose monitor supply (K0553) provided on
November 14, 2019.
You asked the Plan to pay for the supply allowance. You say that you would like reconsideration based on the
records submitted. The Plan denied your request. The Plan says there is no itemized shipping/billing invoice ti
indicate the specific supplies or proof of delivery for the billed date of service.
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 date of service and
supplies provided in this case. Therefore, we decided that the Plan does not have to pay for a continuous
glucose monitor supply (K0553) provided on November 14, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered.
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 claim was not filed timely.
The Plan follows Medicare rules. The rules say that claims for services furnished must be filed no later than one calendar year after the date of service. The record shows that a claim for these services was not filed. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the ankle foot orthosis, LT, RT (L1971x2) provided.
You asked the Plan to pay for the orthoses. You say that please see the attached medical records which prove
the medical necessity of the item and process the claim for payment. The Plan denied your request. The Plan
says the records provided do not support the service billed.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for the orthoses. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the reviewed documentation does not include a provider note, physical examination, imaging
studies, or differential diagnosis. There are no medical records to support the requested orthosis. Medical
necessity cannot be determined.
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 orthoses have not been met. Therefore, we decided that the Plan does not
have to pay for the ankle foot orthosis, LT, RT (L1971x2) provided.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on December 27, 2019.You asked the Plan to pay for the pump assembly and operation. You say that you would like reconsideration because it takes 30 minutes to set up the machine and the perfusionist is required to remain 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 assembly and operation have not been met. Specifically, payment for this service is included in the DRG payment to the facility and is the responsibility of the facility to any vendor.Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump (99190)provided on December 27, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to approve additional payment for eyewear provided.
You asked the Plan to approve additional payment for eyewear. The Plan denied your request. The Plan says that they paid the maximum amount.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers up to a $200 allowance for Non-Medicare covered eyewear every year. The file shows that the plan has approved the maximum yearly benefit of $200 for the requested services. There is no provision in the contract which would require the plan to approve more than this amount. Therefore, we decided that the Plan does not have to approve additional payment for eyewear provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for moderate sedation services (99152) provided.
You asked the Plan to pay for the moderate sedation services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not indicate the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status.
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 99152 is moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older. We find that CPT code 99152 is not supported in the record. Specifically, the record does not indicate the presence of an independent trained observer. Based on this information, we decided that Medicare rules for coverage of the moderate sedation services have not been met. Therefore, we decided that the Plan does not have to pay for moderate sedation services (99152) provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for ankle-foot orthoses (L1971) provided.
You asked the Plan to pay for ankle-foot orthoses. You say that this was medically necessary. The Plan denied your request. The Plan says the documentation does not show that this was medically necessary.
The Plan follows Medicare rules. Medicare rules say that an ankle foot orthosis is covered when the enrollee requires stabilization for medical reasons. 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 ankle-foot orthoses. Our reviewer says that the AFO at issue was not medically necessary. Our physician reviewer found there is no documented deformity or instability. An off-shelf device can address needs. As such, a prefabricated insole or AFO is deemed not medically 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 ankle-foot orthoses have not been met. Therefore, we decided that the Plan does not have to pay for ankle-foot orthoses (L1971) provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the clinic visit and the specialist office visit provided on November 4, 2019 and November 5, 2019.
You asked the Plan to waive the copayments for the clinic visit and the specialist office visit. You say that you were not advised that you would be paying an outpatient surgery copayment. You say you were billed for both an office visit and a test, when you had a test only. 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 $400 copayment per date of service for an outpatient hospital facility and a $40 copayment per specialist visit. You have been asked to pay a $170.66 copayment, which is less than the standard copayment for the clinic visit and a $40 copayment for the specialist office visit. ($170.66 + $40 = $210.66). The clinic visit falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The specialist office visit falls within "Physician/Practitioner services, including doctor's office visits" benefit category.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the clinic visit and the specialist office visit provided on November 4, 2019 and November 5, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for behavioral health services provided on May 2, 2019 to May 16, 2019 by an out of network (OON) provider.You asked the Plan to pay for behavioral health services. You say that a claim for another date of service was paid for a similar service. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says no prior authorization was obtained for these services. The Plan says that the March 19, 2019 date of service was paid due to services being performed during an emergency room visit. The Plan says that these services were not 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 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 behavioral health services provided on May 2, 2019 to May 16, 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 an Emergency Room visit provided
November 21, 2019.
You asked the Plan to waive the copayment for the Emergency Room visit. You say that the service was an
urgent care visit and the copayment should be waived. The Plan denied your request. The Plan says the correct
copayment was applied. The provider confirmed Emergency Room services were provided.
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 Emergency Care.
You have been asked to pay a $50 copayment for the Emergency Room visit. The Emergency Room 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 an
Emergency Room visit provided November 21, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the in network rate for the comprehensive oral exam (D0150), the complete series of periapical x-rays (D0210), and the adjunctive pre-diagnostic testing (D0431) provided on January 7, 2020.You asked the Plan to pay the in network rate for the adjunctive pre-diagnostic testing. You say that you chose this provider off of the list that was sent to you in late 2019. You say that The Plan denied your request. The Plan says the adjunctive pre-diagnostic testing is not a covered service.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 the in network rate for the comprehensive oral exam (D0150), the complete series of periapical x-rays (D0210), and the adjunctive pre-diagnostic testing (D0431) provided on January 7, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided by an out of network (OON) provider.
You asked the Plan to pay for the OON services. You say that your staff works hard to provide the fastest and efficient diagnostic services. The Plan denied your request. The Plan says the enrollee's plan requires utilization of network providers, and authorization for certain services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this case, and the ordering provider are not network providers 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 OON services. Therefore, we decided that the Plan does not have to pay for the lab services provided by an out of network (OON) provider.