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

We decided that the Plan does not have to pay for laboratory testing provided on June 9, 2019.You asked the Plan to pay for lab tests. You say that you are appealing.The Plan denied your request. The Plan says the denial of payment for these services is correct, because these tests were ordered by telemedicine which is a Medicare prohibited action.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 services billed on this claim. Based on this information, we decided that Medicare rules for coverage of lab tests have not been met.Therefore, we decided that the Plan does not have to pay for laboratory testing provided on June 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on September 24, 2019.
You asked the Plan to waive the copayment for the office visit. You say that you told the nurse you had your own cardiologist. You say that you were never told you would have a bill from the doctor. 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 specialist 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 the office visit was for a pre-procedural cardiovascular examination. 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 September 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the wound care service provided.
You asked the Plan to waive the copayment for the wound care service. You say that you have always received in-network coverage at the hospital and have no problems with insurance coverage. You say the service was medically necessary and should be covered by the Plan. 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 $295 copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges. You have been asked to pay a $295 copayment for the wound care service. The wound care service falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the wound care service provided.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care on July 11, 2019.
You asked the Plan to pay for the subsequent nursing facility care. You say that the enrollee was not covered under hospice on the date of service. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care provided on July 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthosis (L1820) provided.
You asked the Plan to pay for the orthosis. You say that the records provided should support the necessity of the services. The Plan denied your request. The Plan says there is insufficient documentation to corroborate the services to confirm that 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 non-covered visit are likewise non-covered. Therefore, we decided that the Plan does not have to pay for knee orthosis (L1820) provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core buildup, including any pins when required on August 7, 2019.You asked the Plan to pay for the core buildup. You say that you contacted the plan and the agents told you that crowns were covered. You also say that code D2950 represents tooth preparation to receive a crown.The Plan denied your request. The Plan says this service is 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 fort he core buildup, including any pins when required, provided on August 7, 2019.Your complaint about the plan selling policies under false pretenses and giving misinformation is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe bilateral ankle foot orthoses (L1971) provided on March 15, 2019.You asked the Plan to pay forthe bilateral ankle foot orthoses.You say that you are requesting a reconsideration of the Plan's denialas the orthotic devices were prescribed as adjunctive therapy to assist in reducing the level of pain the member is experiencing and for overall improvement in the patient's quality of life.The Plan denied your request. The Plan says according to the claims data available at the time of the review, the plan was unable to discover any evidence of an established relationship between the member and the ordering physician. There were no claims submitted for an evaluation and management service. Review of claims history for this member, and a review of the submitted documentation does not contain evidence of a prior Telemedicine or Telehealth service with the ordering physician as required per CMS guidelines.The Plan must follow Medicare rules. Medicare rulessay 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 item ordered following the non-covered visit are likewise non-covered.Therefore, we decided that the Plandoes not have to pay forthe bilateral ankle foot orthoses (L1971) provided on March 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for endocrinology services provided to the enrollee.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says Current Procedural Terminology (CPT) code 94690 59 (1 unit) remains not supported.
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 94690 is "Oxygen uptake, expired gas analysis; rest, indirect (separate procedure)." We asked our coding 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 services. Our reviewer says that the services at issue in this case were supported by the medical records. Our coding reviewer found CPT code 94690 is not supported. The record does not contain evidence that a lung function test including oxygen uptake and expired gas analysis at rest was performed during this episode of care. 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 services have not been met. Therefore, we decided that the Plan does not have to pay for endocrinology services provided to the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided on June 17, 2019.You asked the Plan to waive the copayment for an office visit. You say that this was an annual wellness visit and you should not owe a copayment.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 copayment for primary care provider visits.The medical records show that you received services beyond an annual wellness exam on June 17, 2019. Therefore, you are responsible to pay the $10 copayment.  You have been asked to pay a $10 copayment for an office visit. An 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 an office visit provided on June 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for spinal manipulation (98940), electrical stimulation (97032), office visits (99202), and an x-ray (72100) provided from June 29, 2019 to July 19, 2019 by out of network provider.You asked the Plan to pay for spinal manipulation, electrical stimulation, office visits, and an x-ray. You say that this provider is the only provider whose treatment can help you.The Plan denied your request. The Plan says these services were not authorized and are available in-network.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 rules also say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.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 services.Furthermore, apart from spinal manipulation, these services are not covered by Medicare or the Plan.Therefore, we decided that the Plan does not have to pay for spinal manipulation (98940), electrical stimulation (97032), office visits (99202), and an x-ray (72100) provided from June 29, 2019 to July 19, 2019 by out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from April 14, 2019 to April 17, 2019.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you were only inpatient 2 days and disagree with the 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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $295 copayment per day for days 1-7 for inpatient hospital care. The medical records show that you had an inpatient hospital stay from April 14, 2019 to April 17, 2019. Therefore, you are responsible to pay a $295 copayment for days 1-3 (April 14, 2019 to April 16, 2019). $295 (copayment) x 3 (inpatient days) = $885.00. You have been asked to pay the total copayment amount of $885.00 for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital 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 inpatient hospital stay from April 14, 2019 to April 17, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forthe stress test andmyocardial perfusion provided on July 10, 2019.You asked the Plan to waive the copayments forthe stress test and myocardial perfusion. You say that you were not informed about a copayment. You say that you do not have the money to pay.The Plandenied your request. The Plan says the copayments 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 $25 copayment for Medicare-covered non-radiological diagnostic services and a $100 copayment for each Medicare-covered radiological diagnostic service.You have been asked to pay a $25 copayment for the stress test and a $100 copayment for the myocardial perfusion. The total amount you owe is $125 ($25 + $100 = $125). The stress test and myocardial perfusion fall 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 copayments forthe stress test and myocardial perfusion provided on July 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pay forneurology services (CPT 95941) provided to the enrollee on June 10, 2019.You asked the Planto pay forthe serivces. You say that this should be paid for.The Plandenied your request. The PlansaysCPT 95941 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 95941 is not supported in the medical record. Specifically, this code has a status indicator of I according to the Medicare Physician's Fee Schedule. This indicates that the code is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the serivces have not been met.Therefore, we decided that the Plandoes not haveto pay forneurology services (CPT 95941) provided to the enrollee on June 10, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided on August 12, 2019.You asked the Plan to pay for the services. You say that this should be paid for.The Plan denied your request. The Plan says Healthcare Common Procedure Coding System (HCPCS) G0483 (1 Unit) remains not supported.The Plan must follow Medicare rules. Medicare rules say that a physician order must be present for labs to be covered.The documentation submitted did not include a physician order/lab requisition or medical records stating exactly tests were to be performed. 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 for drug testing services provided on August 12, 2019.
Appeal type: Imaging
Decision: Unfavorable

e decided that the Plan does not have to pay foran X-ray of the ankle (73610) provided August 20, 2019 by "the provider" .You asked the Plan to pay forthe X-ray. You say that the claim was not a duplicate because there was multiple exams performed on the same date.The Plan denied your request. The Plan says the service atissue was already paid under a duplicate claim number.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 73610 is not supported in the medical record. Specifically, the service at issue was already paid under a claim number . The additional claim submitted did not correctly denote that it was for a repeat service. Based on this information, we decided that Medicare rules for coverage of the X-ray have not been met.Therefore, we decided that the Plan does not have to pay foran X-ray of the ankle (73610) provided August 20, 2019 by "the provider".
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay fordrug testing provided by the provider on June 10, 2019.You asked the Plan to pay fordrug test. You say that you are appealing with a requisition form, results, and physician's custom profile to support the service billed.The Plan denied your request. The Plan says the denial of payment for this service is correct, because the documentation submitted does not include lab results or a valid physician order, lab requisition, or medical records stating exactly which tests were to be billed. The Plan also says that the records indicate that saliva drug testing was to be performed, therefore the billed code cannot be verified.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 does not include a physician order or clear intent to order the specific lab service billedon 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 provided on June 10, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy services provided to the enrollee from August 13, 2019 to August 20, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says this code 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 code. We find that HCPCS code S9328 is not supported in the medical record. Specifically, this code has a status indicator of I according to the Medicare Physician's Fee Schedule. This indicates that the code is not valid for Medicare purposes.. 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 for home infusion therapy services provided to the enrollee from August 13, 2019 to August 20, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not haveto waive the copayment for the tissue exam provided on September 5, 2019.You asked the Plan to waive the deductible and the copayment forthe tissue exam. You say that you already paid $166.43 for this and you do not know why you are receiving another $10 copayment.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 $10 copayment for in-network diagnostic lab services and diagnostic procedures and tests (per day, per facility). You have been asked to pay a $10 copayment for the tissue exam. The tissue exam falls within "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 tissue exam provided on September 5, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on April 15, 2019 by an out of
network provider.
You asked the Plan to pay for home infusion supplies. You say that you would like this claim reprocessed and
approved for payment. The Plan denied your request. The Plan says the have correctly denied payment for the
service in question.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the medical services provided on April 15, 2019
by an out of network provider.