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

We decided that the Plan does not have to pay forsurgical preparation by excision of open wounds (15002 and 15003) provided on September 25, 2018.You asked the Plan to pay forsurgical preparation by excision of open wounds. You say that this should be covered.The Plan denied your request. The Plan says the record does not support these codes.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 15002 is surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, trunk, arms, legs; first 100 sq cm or 1% of body area of infants and children. The definition of 15003 is surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, trunk, arms, legs; each additional 100 sq cm, or part thereof, or each additional 1% of body area of infants and children (List separately in addition to code for primary procedure).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 surgical preparation by excision of open wounds. Our reviewer says that these codes are not supported by the record. Our physician reviewer found the record does not contain evidence that surgical preparation of a recipient site for a skin graft was performed during this episode of care.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of surgical preparation by excision of open wounds have not been met.Therefore, we decided that the Plan does not have to pay forsurgical preparation by excision of open wounds (15002 and 15003) provided on September 25, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe chiropractic manipulations, 3 to 4 regions, provided from August 19, 2019 to August 28, 2019 by the out of network provider.You asked the Plan to pay forthe chiropractic care. You say that the services were provided to the enrollee in good faith.The Plan denied your request. The Plan says authorization was not obtained before the services were provided to the enrollee. The Plan says the enrollee's primary care physician did not refer them for the services.The Plan also says that 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 forthe chiropractic manipulations, 3 to 4 regions, provided from August 19, 2019 to August 28, 2019 by the out of network provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the shoulder, elbow, wrist, elbow orthosis (SEWHO) (L3960) provided.
You asked the Plan to pay for the orthosis. You say that the records provided should support the necessity of the orthosis. The Plan denied your request. The Plan says there is insufficient documentation to corroborate the service so that the Medicare coverage criteria has been met.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for the shoulder, elbow, wrist, elbow orthosis (SEWHO) (L3960) provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the diabetic supplies provided to the enrollee.
You asked the Plan to pay for the diabetic supplies. The Plan denied your request. The Plan says that a valid proof of delivery was not submitted.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The tracking ticket does not include the items supplied and the delivery ticket does not include a tracking number to confirm it was delivered. Therefore, we decided that the Plan does not have to pay for the diabetic supplies provided to the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay fordrug testing provided by the provider on July 3, 2019.You asked the Plan to pay fordrug test. You say that this testing had a valid order and the correct code was billed.The Plan denied your request. The Plan says the denial of payment for this service is correct, because the documentation submitted did not include a valid physician order, lab requisition, or medical records signed by the ordering physician to order this testing.The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include a valid physician order or clear intent to order the specific lab test billed on this claim. Based on this information, we decided that Medicare rules for coverage of drug test have not been met.Therefore, we decided that the Plan does not have to pay fordrug testing providedon July 3, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe skilled nursing facility (SNF) services provided July 6, 2019 to July 30, 2019.You asked the Plan to pay forthe SNF services. You say that you feel that the plan should cover for SNF services.The Plan denied your request. The Plan says medical necessity cannotbe established for continued SNF level of coverage.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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found thereare no identifiable skilled nursing and skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis and does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay foran arthroscopy procedure with code 29999 provided the provider on June 26, 2019.You asked the Plan to pay foroutpatient surgery. You say that this unlisted code is comparable to procedure code 27062 and should be reprocessed for payment.The Plan denied your request. The Plan says the denial of payment for this service is correct, because this code is not eligible for payment to an ambulatory surgical center.The Plan must follow Medicare rules. Medicare rules say that procedure code 29999 is excluded from the list of covered ambulatory surgical center procedures and is not eligible for payment to an ambulatory surgical center. We looked at the file and Medicare rules. The code billed is excluded from coverage for ambulatory surgical centers. Based on this information, we decided that Medicare rules for coverage of outpatient surgery have not been met.Therefore, we decided that the Plan does not have to pay foran arthroscopy procedure with code 29999 provided on June 26, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin based composite (D2330), and sales tax (D9985) provided by the dentist, on August 9, 2019.
You asked the Plan to pay for the dental services. You say that your increased need for so much dental work is a result of mold exposure, steroid medications, and hard candies to curb your smoking habit. The Plan denied your request. The Plan says the annual maximum benefit of $1,000 has been exceeded. The Plan says that any charge which exceeds the annual maximum benefit is your responsibility. The Plan also says that sales tax is not medical in nature and cannot be paid for by the Plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage and fillings are a covered service, the annual maximum benefit of $1,000 has been exceeded. The record shows the annual maximum benefit was reached in the processing of the claim for services that you received on July 2, 2019. Additionally, sales tax is not medical in nature and cannot be paid for by the Plan. Therefore, we decided that the Plan does not have to pay for the resin based composite (D2330), and sales tax (D9985) provided by the dentist, on August 9, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the ankle/foot orthosis RT,LT (L1971) provided by the provider. on April 2, 2019.
You asked the Plan to pay for the orthosis. You say that you are submitting the medical record as evidence. The Plan denied your request. The Plan says there is no evidence of an established relationship between the enrollee and the ordering physician. There were no claims submitted for an evaluation and management service and there is insufficient documentation to corroborate the services so we can confirm Medicare coverage criteria has been met.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for the ankle/foot orthosis RT,LT (L1971) provided by the provider on April 2, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe glucose monitor, test strips, lancets, control solution , and lancet device provided by "the provider" from May 13, 2019 to August 1, 2019.You asked the Plan to pay forthe glucose monitor (E2100),test strips (A4253), lancets (A4259), control solution (A4256), and lancet device (A4258). Yousay that The Plan should pay this claim.The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered.Therefore,we decided that the Plan does not have to pay forthe glucose monitor, test strips, lancets, control solution , and lancet device provided by "the provider" from May 13, 2019 to August 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forinpatient physician services provided to the enrollee on July 10, 2019.Youasked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says payments for physician services provided during inpatient care areincluded in the facility payment.You asked the plan to pay for this service. You say that this claim should be paid. The plan denied your request. The plan says this claim cannot be paid separately based on Medicare guidelines for inpatient services. 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 this service would have been included under the facility claim. Payment to you for this service is the responsibility of the facility or hospital. Therefore, we decided that the Plan does not have to payforinpatient physician services provided to the enrollee on July 10, 2019
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit provided by the Hospital on July 12, 2019 to July 13, 2019.
You asked the Plan to waive the copayment for an emergency room visit. You say that you feel like the wording is misleading. You say that you were admitted and you can't have observation services if you are not an inpatient. The Plan denied your request. The Plan says the correct copayment has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance).Enrollee's contract with the Plan clearly says that enrollees must pay a $60 copayment for emergency care. Enrollee has been asked to pay a $60 copayment for an emergency room visit. Evidence shows that you were never formally admitted as an inpatient. Evidence shows that observation services were provided; therefore, the emergency room copayment cannot be waived. An emergency room visit falls within the emergency care benefit category. This means that Enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an emergency room visit provided by Hospital on July 12, 2019 to July 13, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the fillings (D2332 x3) provided on August 6, 2019.You asked the Plan to pay for the fillings (D2332 x3). You say that you took out extra dental coverage in May 2019. The Plan denied your request. The Plan says the maximum benefit limit has been reached.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 Plan also has a maximum benefit of $1,000 per year. The fillings (D2332 x3) are not covered because you have already received the maximum benefit amount from the plan in 2019. The record shows the Plan reached the $1,000 annual benefit maximum on August 2, 2019. Therefore, we decided that the Plan does not have to pay forthe fillings (D2332 x3) provided on August 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fortest strips, lancets, control solution, and batteries provided by "the provider" from August 5, 2019 to October 24, 2019.You asked the Plan to pay fortest strips (A4253), lancets (A4259), control solution (A4256), and batteries (A4235). You say that The Plan should pay this claim.The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate theDelivery Ticket.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid and proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered.Therefore, we decided that the Plan does not have to pay fortest strips, lancets, control solution, and batteries provided by "the provider" Supplies from August 5, 2019 to October 24, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forpacemaker insertion surgery provided by the provider from July 26, 2019 to July 27, 2019.You asked the Plan to waive the coinsurance forpacemaker surgery. You say that you are appealing.The Plan denied your request. The Plan says the coinsurance amount you are being charged is correct.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 30% coinsurance for out-of-network outpatient surgery provided at an outpatient hospital. The allowed amount of the claim is $10,013.85, however you have only been asked to pay $2,989.80 which is less than 30% coinsurance for out-of-network outpatient surgery.You have been asked to pay $2,989.80, which is less than 30% coinsurance for pacemaker surgery. Pacemaker surgery falls within the Outpatient Surgery and Other Medical Services Provided at Hospital OutpatientFacilities 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 coinsurance forpacemaker insertion surgery provided from July 26, 2019 to July 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic manipulative treatments for 3-4 regions, and the office visit provided from May 20, 2019 to June 14, 2019 by out of network provider.You asked the Plan to pay for the chiropractic care. You say that you were not aware that you needed to check authorization. You say that you were advised by the office staff that they accept Medicare. You also say that you were unaware that the provider was not in network.The Plan denied your request. The Plan says authorization was not obtained before you received the 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 is not a network provider with the Plan. 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 manipulative treatments for 3-4 regions, and the office visit provided from May 20, 2019 to June 14, 2019 by out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe diabetic supplies provided to the enrollee from June 17, 2019 to September 5, 2019.You asked the Plan to pay forthe diabetic supplies. The Plan denied your request. The Plan says that valid proof of delivery was not submitted.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the itemsat issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The tracking ticket does not include the items supplied and the delivery ticket does not include a tracking number to confirm it was delivered.Therefore, we decided that the Plan does not have to pay forthe diabetic supplies provided to the enrollee from June 17, 2019 to September 5, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for test strip, lancets, control solution, and batteries provided from July 16, 2019 to October 4, 2019.You asked the Plan to pay fortest strips (A4253), lancets (A4259), control solution (A4256), and batteries (A4235). You say that The Plan should pay this claim.The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid and proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered.Therefore, we decided that the Plan does not have to pay fortest strip, lancets, control solution, and batteries provided from July 16, 2019 to October 4, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe periodic oral evaluation, prophylaxis and intraoral x-rays provided on March 22, 2019.You asked the Plan to pay forthe periodic oral evaluation, prophylaxis and intraoral x-rays. You say that there were no in-network provider available in your area.The Plan denied your request. The Plan says services performed by an out-of-network dentist 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 requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe periodic oral evaluation, prophylaxis and intraoral x-rays provided on March 22, 2019.