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

We decided that the Plan does not have to pay forthe medical services provided on May 20, 2019 by an out of network provider.You asked the Plan to pay foroutpatient lab work. You say that you would like to respectfully request that this service be retroactive authorized and processed for payment.The Plan denied your request. The Plan says no prior authorization was obtained for this service.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 theitems/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 medicalservices provided on May 20, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for plastic surgery services (CPT 13122 and CPT 15734) provided to the enrollee on June 18, 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 the denied codes are not supported by the medical records submitted.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 the denied codes is:CPT 15734:Muscle, myocutaneous, or fasciocutaneous flap; trunk CPT 13122:Repair, complex, scalp, arms, and/or legs; each additional 5 cm or less (List separately in addition to code for primary 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 not coded correctly. Our coding reviewer found CPT code 15734 is not supported. The record does not contain evidence that a myocutaneous fasciocutaneous flap was created to repair a defect. Additionally, CPT code 13122 is not supported. This is an add-on code for additional repair. According to the medical record and CPT rules, the primary procedure code should be reported, not the add-on code.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 plastic surgery services (CPT 13122 and CPT 15734) provided to the enrollee on June 18, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an ambulance trip provided on July 7, 2019.You asked the Plan to waive the deductible for an ambulance trip. You say that you 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. Your contract with the Plan says that there is a $750 deductible for ambulance services. You had an ambulance trip on July 7, 2019. The record shows that you had only paid $9.22 toward the $750 deductible. Therefore, you are responsible to pay the allowed amount of $358.40.The item or service you asked the Plan to waive the deductible for falls within the benefit category ambulance services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible for ambulance services. This cost sharing is a contractual obligation that had not been met at the time an ambulance trip was received on July 7, 2019.Therefore, we decided that the Plan does not have to waive the deductible for an ambulance trip provided on July 7, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from April 29, 2019 through April 30, 2019.
You asked the Plan to pay for inpatient hospital services. You say that the claim should be paid. The Plan denied your request. The Plan says the billed service for April 29, 2019 through April 30, 2019, denied with reason 0144 - Missing Clinical Trial Information. The Plan states the clinical trial number billed on the claim is invalid and per Medicare guidelines the appropriate information is required to pay claim.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient hospital services have not been met. A review of our claims system shows Clinical Trial #01972282 was billed on claim; however, the Clinical Trial number submitted is not listed on the Transcatheter Mitral Valve Repair (TMVR), which means it is not an approved code. Per the 2150 Review for Coverage with Evidence Development (CED) Review is required criteria defined by the appropriate National Coverage Determination or a Reimbursement policy. Therefore, we find the Medicare rules for payment as not been met. If the provider determines that a billing error occurred during the initial submission of the denied claim, the plan would accept a submission of a corrected claim to consider for payment. Therefore, we decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from April 29, 2019 through April 30, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services provided on June 17, 2019. You asked the Plan to pay for the radiology services. You say that the payment was recouped for no valid reason.The Plan denied your request. The Plan says Original Medicare is responsible for services related or unrelated to the enrollee's terminal condition, during the hospice election.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 radiology services provided on June 17, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the discharge services (CPT 99239) provided to the enrollee on February 5, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed service cannot be verified.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 99239 is "Hospital discharge day management; more than 30 minutes".We find that CPT code 99239 is not supported in the medical record. Specifically, the records provided do not support that more than 30 minutes of discharge day management services were provided on the date of service in question. 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 the discharge services (CPT 99239) provided to the enrollee on February 5, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on July 15, 2019.You asked the Plan to pay fo rthe orthosis. You say that the claim should be paid.The Plan denied your request. The Plan says the enrollee has previously received the same supplies within the 5-year RUL.The plan must follow Medicare rules. Medicare rules say that the reasonable useful lifetime of durable medical equipment is no less than five years. Replacement equipment may be granted when irreparable wear or irreparable damage is demonstrated or there has been a change in the enrollee's medical condition. We looked at the file and Medicare rules. In this instance, the submitted documentation indicates that the enrollee has received the same durable medical equipment on June 1, 2018. This orthosis is still within the 5-year RUL and the documentation submitted does not show that the orthosis is irreparably worn, irreparably 
damaged, or that the enrollee had a change in medical condition to warrant the orthosis at issue.  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 fora lumbar-sacral orthosis (L0650) provided to the enrollee on July 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a sensorimotor examination provided on March 15, 2019.You asked the Plan to waive the copayment fora sensorimotor examination. You say that you feel that you should only owe a $50 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 $65 copayment for diagnostic procedures or tests.You have been asked to pay a $65 copayment for a sensorimotor examination. A sensorimotor examination falls 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 copayment for a sensorimotor examination provided on March 15, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing services provided to Beneficiary on May 23, 2019.You asked the Plan to pay forthe drug testing services. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order/lab requisition.The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met.Therefore, we decided that the Plan does not have to pay forthe drug testing services provided to the beneficiary on May 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the mechanical traction(97012), manual therapy (97140), and electrical stimulation (97032) provided on May 31, 2019.You asked the Plan to pay for the mechanical traction, manual therapy, and electrical stimulation.You say that you are requesting a reconsideration of the plan's denial.The Plan denied your request. The Plan says the services provided are not a covered benefit under the member's policy.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 services at issue are not manual manipulation of the spine.Therefore, we decided that the Plan does not have to pay for the mechanical traction (97012), manual therapy (97140), and electrical stimulation (97032) provided on May 31, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for ankle-foot orthotics provided on March 29, 2019.
You asked the Plan to pay for ankle-foot orthotics. You say that you are appealing with records. The Plan denied your request. The Plan says the denial of payment for these items is correct, because these items were ordered by telemedicine and there is no evidence of an established relationship between the enrollee and the ordering physician.
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 ankle-foot orthotics provided on March 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

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 12, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network deficiency for 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 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 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 99190) provided to the enrollee on July 26, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment for this service would be included in the Part A DRG payment to the facility.
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 all fees related to this service would have been included under the facility claim. Therefore, we decided that the Plan does not have to pay for the services (CPT 99190) provided to the enrollee on July 26, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for ridge augmentation (D7950) and extraction of tooth (D7210) provided by your dentist on August 20, 2019.
You asked the Plan to pay for the dental services. You say that you thought you were only getting a tooth extracted and did not know you would need surgery. You were also new to the area and thought Passport would give you time to find new providers. The Plan denied your request. The Plan says these services are not covered benefits under 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. The health plan contract specifically says that any services not listed are not covered. 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 for ridge augmentation (D7950) and extraction of tooth (D7210) provided by your dentist on August 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 14, 2019 by an out of network provider.
You asked the Plan to pay for nerve studies. You say that you are appealing with medical records. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and the referring physician is also out-of-network with the Plan.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 August 14, 2019 by the out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for diabetic supplies provided by the practice from July 23, 2019 to October 11, 2019.
You asked the Plan to pay for diabetic supplies. You say that you are appealing with records. The Plan denied your request. The Plan says the denial of payment for these items is correct, because the delivery ticket submitted did not include the carrier's tracking number nor did the proof of delivery include an order number to corroborate the delivery ticket submitted.
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider payment for any item or service, the information by the supplier must corroborate the documentation in the medical record and confirm that Medicare coverage criteria have been met. The rules say that the supplies must furnish sufficient information to the Plan to determine whether payment is due for a claim. We looked at the file and Medicare rules. The delivery ticket submitted is not signed by the recipient, nor is the delivery ticket corroborated by the proof of delivery submitted. Therefore, you have not furnished sufficient information to the Plan to justify payment of this claim as billed. Based on this information, we decided that Medicare rules for coverage of diabetic supplies have not been met. Therefore, we decided that the Plan does not have to pay for diabetic supplies provided by this practice from July 23, 2019 to October 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for test strips, lancets, control solution, and batteries provided by the provider on August 2, 2019.
You asked the Plan to pay for test 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 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 for test strips, lancets, control solution, and batteries provided by the provider on August 2, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for test strips, lancets, control solution, and batteries provided by the practice from August 4, 2019 to October 23, 2019.
You asked the Plan to pay for test 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 for test strips, lancets, control solution, and batteries provided from August 4, 2019 to October 23, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the wrist hand orthosis provided by the provider on March 1, 2019.
You asked the Plan to pay for the wrist hand orthosis (L3916). You say that the Plan should pay this claim. The Plan denied your request. The Plan says rules for telehealth services have not 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 wrist hand orthosis provided by the provider on March 1, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay forthe emergency room (ER) services rendered to"the beneficiary" by "the provider" on June 1,2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 99283 is not separately payable.The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.The provider submitted a claim for procedure codes 99283 and 99284. Code 99283 is a column II code with a modifier indicator of 1 when billed with column I code 99284. Code 99283 was not billed with an appropriate modifier to allow for separate payment.Therefore, we decided that the Plan does not have to pay forthe emergency room (ER) services rendered to "the beneficiary" by "the provider" on June 1, 2019.