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

We decided that the Plan does not have to pay for arthrodesis (22551 and 22552) and the insertion of a spinal device (22845 and 22853) provided on November 27, 2019.
You asked the Plan to pay for the arthrodesis and spinal device. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the records do not support the services billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT codes 22551, 22552, 22845 and 22853 are not supported in the record. Specifically, the date of service recorded in the medical records do not reflect the billed date of service. Based on this information, we decided that Medicare rules for coverage of the arthrodesis and spinal device have not been met. Therefore, we decided that the Plan does not have to pay for arthrodesis (22551 and 22552) and the insertion of a spinal device (22845 and 22853) provided on November 27, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the golimumab injection provided on December 19, 2019.
You asked the Plan to waive the coinsurance for the injection. You say that you were told that this would cost less than you are being charged. The Plan denied your request. The Plan says that the claim processed 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 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay a 20% coinsurance for the injection. The injection falls within the Medicare Part B prescription drugs 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 for the golimumab injection provided on December 19, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance fora Medicare Part B drug injection provided on November 25, 2019.You asked the Plan to waive the coinsurance fora Medicare Part B drug injection. You say that you were shocked by the charges and disagree with your cost-sharing 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 20% coinsurance for Medicare PartB prescription drugs. You received a Medicare Part B drug injection on November 25, 2019. The allowed amount is $2,359.38 and 20% of that is $471.88. You have been asked to pay the total coinsurance amount of $471.88 for a Medicare Part B drug injection. A Medicare Part B drug injection falls within the Medicare Part B prescription drugs 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 youagreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the coinsurance fora Medicare Part B drug injection provided on November 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for electric stimulation therapy (97014) and mechanical traction therapy (97012) provided on October 18, 2019 through November 13, 2019.
You asked the Plan to pay for the electric stimulation therapy and mechanical traction therapy. You say that you would like reconsideration as the services rendered were medically necessary. The Plan denied your request. The Plan says Medicare does not cover non-manipulative services provided by chiropractors.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for electric stimulation therapy (97014) and mechanical traction therapy (97012) provided on October 18, 2019 through November 13, 2019.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pay for outpatient physical therapy provided from July 24, 2019 to July 25, 2019.
You asked the Plan to pay for outpatient therapy. You say that the enrollee was visiting family outside of the Plan's service area and needed service to keep her knee progressing after surgery. The Plan denied your request. The Plan says that the denial of payment for these services is correct, because this provider is out-of-network with the Plan and the services were not urgent or emergent in nature. The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has not provided medical records or documented attempts to obtain medical records for these services. We requested this information, but it was not provided to us. Without this information, we cannot determine whether the services rendered meet the Medicare criteria for urgent, out-of-area care. Therefore, the Plan has not shown that its decision to deny payment for these services is correct or justified by Medicare rules and the Plan contract. Therefore, we decided that the Plan has to pay for outpatient physical therapy provided from July 24, 2019 to July 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on November 8, 2019 by an out of network (OON) provider.You asked the Plan to pay for the physician services. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.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 physician services provided on November 8, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forlab work provided on September 17, 2019 by an out of network (OON) provider.You asked the Plan to pay forlab work. You say that you rely on the referring physician to obtain prior authorization. You say that if authorization was not obtained you should not be penalized for this error.The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the referring provider is also out-of-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 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 forlab work provided on September 17, 2019 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the Nursing Facility Visit (99309) provided on September 8, 2019. You asked the Plan to pay for the nursing facility care. You say that the services were medically necessary. The Plan denied your request. The Plan says there were in-network providers available to perform the services at issue. 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 Nursing Facility Visit (99309) provided on September 8, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran ultrasound provided by doctor on January 23, 2020.You asked the Plan to waive the copayment foran ultrasound. You say that you had the incorrect ultrasound done. You say that you should not be held responsible for it.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). Your contract with the Plan clearly says that you must pay a $40 copayment for outpatient diagnostic tests/ultrasound. You have been asked to pay a $40 copayment for an ultrasound. Since an ultrasound was provided the correct copayment has been applied. An ultrasound falls within the outpatient diagnostic tests/ultrasound 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 ultrasound provided by doctor on January 23, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forhome health services provided on July 2, 2019 to July 5, 2019 by an out of network (OON) provider.You asked the Plan to pay forOON home health services. You say that you believed you were 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 forhome health services provided on July 2, 2019 to July 5, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forlumbar-sacral orthosis (L0648) provided December 13, 2019.You asked the Plan to pay forthe orthosis. You say that the records provided should support the necessity of the service in dispute.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. 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 attemptsto obtain the physician order and proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid  physician order and proof of delivery  or a delivery ticket for the supplies provided in this case.Therefore, we decided that the Plan does not have to pay forlumbar-sacral orthosis (L0648) provided December 13, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ER visit provided on August 2, 2019.You asked the Plan to waive the copayment for an ER visit. You say that your cut opened back up and you had to return to the ER.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 $90 copayment for emergency care. You have been asked to pay a $90 copayment for an ER visit. An ER 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 thePlan.Therefore, we decided that the Plan does not have to waive the copayment foran ER visit provided on August 2, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis provided by on November 15, 2019.
You asked the Plan to pay for the lumbar-sacral orthosis. You say that the Plan should pay this claim. The Plan denied your request. The Plan says documents were altered.
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 physician order for the items at issue in this appeal. The record does not contain a valid physician order for the supplies provided in this case. The physician order is dated after the date of service. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on November 15, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four testing (95999) provided on August 19, 2019.
You asked the Plan to pay for train of four testing. You say that this was medically necessary. The Plan denied your request. The Plan says payment of this service is bundled into other services.
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 95999 is not supported in the medical record. Specifically, the use of unlisted CPT code 95999 to report train of four testing is not supported. According to CPT coding rules, train of four testing is not a separately reportable procedure and is included in the other interoperative neuromonitoring procedures. Based on this information, we decided that Medicare rules for coverage of train of four testing have not been met. Therefore, we decided that the Plan does not have to pay for train of four testing (95999) provided on August 19, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-ofnetwork
provider on July 29, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that
the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider
on July 29, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient surgical services rendered on
December 18, 2019.
You asked the Plan to waive the copayment for these services. You say that you would like to only be billed for
an office visit. The Plan denied your request. The Plan says the copayment was 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). The enrollee's contract with the Plan clearly says that enrollees
must pay a $275 copayment for each Medicare-covered outpatient surgery in an ambulatory surgical center or
hospital outpatient facility.
Review of the file shows that the enrollee received outpatient surgical services on December 18, 2019. Per the
contract with the Plan, there is a $275 copayment for each Medicare-covered outpatient surgery in an
ambulatory surgical center or hospital outpatient facility. This cost sharing is a contractual obligation the
enrollee agreed to pay upon enrolling in the Plan. However, the Medicare allowed amount for these services
was $224.68. Given that the allowed amount was less than the $275 copayment, the enrollee has been asked to
pay $224.68 for these services.
Therefore, we decided that the Plan does not have to waive the copayment for the outpatient surgical services
rendered on December 18, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services (97026, 97012, 97014, 97032)
provided on October 15, 2019 to December 3, 2019 by an out of network (OON) provider.
You asked the Plan to pay for OON physical therapy services. You say that these services helped you to feel
better. 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 physical therapy services (97026, 97012,
97014, 97032) provided on October 15, 2019 to December 3, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for initial hospital care service (99222) provided August 26,
2019.
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 an inpatient claim cannot be paid because the enrollee was admitted to
observation level care.
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 99222 is not supported in the medical record. Specifically, code 99217 for observation
care was already paid for this stay. Inpatient claims cannot be paid for an enrollee receiving observation level
service. 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 initial hospital care service (99222)
provided August 26, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy services (HCPCS S9328) provided to the enrollee from December 27, 2019 to December 31, 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 is an invalid procedure code for this service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate procedure code. In this case, the CPT Code Manual definition of HCPCS code S9328 is "Home infusion therapy, implanted pump pain management infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem." 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 (HCPCS S9328) provided to the enrollee from December 27, 2019 to December 31, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from April 1, 2019 to April 30, 2019.
You asked the Plan to pay for home health services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the provider has billed with the incorrect type of bill.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered.
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, this claim has been submitted with an invalid type of bill code. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from April 1, 2019 to April 30, 2019.