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

We decided that the Plan does not have to pay for the basic life support, non-emergency transport services provided on December 24, 2019 by an out of network (OON) provider.You asked the Plan to pay for the ambulance transport services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not a covered benefit.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 basic life support, non-emergency transport services provided on December 24, 2019by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing rendered.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for wound care provided at an outpatient hospital facility.
You asked the Plan to waive the copayments for wound care. You say that you were not informed that you would be receiving outpatient hospital services. 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 $395 copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers. You received wound care at an outpatient hospital facility. Wound care is considered an outpatient surgical procedure. Therefore, you are responsible to pay the total allowed amount of $1,132.38, which is less than the total copayment amount. You have been asked to pay the total amount of $1,132.38 for wound care. Wound care 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 copayments for wound care provided at an outpatient hospital facility.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services provided on November 29, 2018.You asked the Plan to pay forthe laboratory 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 are not supported.The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, however, 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. We find that payment for the lab services is not supported in the medical record. We find that the issue of intent is not clear. There are no medical records in the case file in regards to the physician's intent that the test be performed priorto services taking place.Therefore, we decided that the Plan does not have to pay forthe laboratory services provided on November 29, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia for a lumbar epidural injection provided to the
enrollee on September 23, 2019.
You asked the Plan to pay for the anesthesia. You say that this is medically necessary. The Plan denied your
request. The Plan says the use of general anesthesia for routine pain procedures is warranted only in unusual
circumstances.
The Plan must follow Medicare rules. Medicare rules say that documentation must clearly establish the need
for moderate sedation/MAC during lumbar epidural injections.
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 anesthesia. Our reviewer says that the
services at issue in this case were not medically reasonable or necessary. Our physician reviewer found the
anesthesia start and stop times record an 11-minute duration. During this 11-minute timeframe the enrollee was
given intravenous Propofol and Lidocaine. Epidural steroid injections are typically performed in an ambulatory
setting without sedation and without the services of an anesthesiologist. There is nothing contained in the
submitted documentation to warrant anesthesia services for this procedure. The provided medical records do
not support the use of anesthesia for this procedure.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the anesthesia have not been met. Therefore, we decided that the Plan does not
have to pay for anesthesia for a lumbar epidural injection provided to the enrollee on September 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on November 14, 2019.
You asked the Plan to waive the copayment for a specialist visit. You say that this was a follow-up visit and you should not be responsible for 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 $50 copayment for services obtained by a specialist. You had a specialist visit on November 14, 2019. Follow-up visits are subject to cost-sharing charges. Therefore, you are responsible to pay the $50 copayment. You have been asked to pay a $50 copayment for a specialist visit. A specialist 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 a specialist visit provided on November 14, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the removal of an implantable defibrillator pulse generator 
You asked the Plan to waive the coinsurance for the removal of an implantable defibrillator pulse generator. You say that the services were medically necessary. 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 30% coinsurance for outpatient surgery services provided in an outpatient hospital facility. You have been asked to pay $5,472.71, which is less than the 30% coinsurance for the removal of an implantable defibrillator pulse generator. The removal of an implantable defibrillator pulse generator falls within the outpatient surgery, including 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 coinsurance for the removal of an implantable defibrillator pulse generator
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the oral appliance (E0486) to be provided by an out of network (OON) provider.You asked the Plan to pre-approve the oral appliance. You say that the appliance is medically necessary.The Plan denied your request. The Plan says the service is not emergent and there are network providers available.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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.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. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approve the oral appliance (E0486) to be provided by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the arthrocentesis services (20600) provided.
You asked the Plan to waive the deductible for the arthrocentesis services. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received arthrocentesis services on the date of service at issue in this appeal. The Plan says that the correct amount applied towards your deductible per your contract with the Plan.
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 Physician/Practitioner services. The item or service you asked the Plan to waive the deductible for falls within the benefit category Physician/Practitioner services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible for Physician/Practitioner services. This cost sharing is a contractual obligation that had not been met at the time the arthrocentesis services were received. Therefore, we decided that the Plan does not have to waive the deductible for the arthrocentesis services (20600) provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the podiatry services provided on April 16, 2019 to September 26, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. The Plan denied your request. The Plan says no prior authorization was obtained for non-urgent 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 podiatry 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 podiatry services provided on April 16, 2019 to September 26, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on November 12, 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 November 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the ankle foot orthosis (L1971) provided January 15, 2020.You asked the Plan to pay for the orthosis. You say that please see the attached medical records which prove the medical necessity of the item and process the claim for payment.The Plan denied your request. The Plan says the records provided do not support the service billed.The Plan must follow Medicare rules. Medicare has specific coverage criteria for each type of orthosis. There is no evidence of an established relationship between the enrollee and the ordering physician, there was no claims submitted for an evaluation and management service and there is no evidence of a relationship with the ordering physician as required per CMS guidelines. Based on this information, we decided that Medicare rules for coverage of the orthosis have not been met.Therefore, we decided that the Plan does not have to pay for the ankle foot orthosis (L1971) provided January 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Smart Light Switches.You asked the Plan to pre-approvethe light switches. You say that the light switches are medically necessary.The Plan denied your request. The Plan says the requested items are not a covered benefit.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plan does not have to pre-approveSmart Light Switches.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on January 27, 2020 by an out of network (OON) provider.You asked the Plan to pay for the OON services. The Plan denied your request. The Plan says there is no network deficiency for the services, and alternate network providers were found.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 OON services.Therefore, we decided that the Plan does not have to pay for the lab services provided on January 27, 2020 by an out of network (OON) provider
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye exam (92014) and refraction (92015) provided January 8, 2020.
You asked the Plan to pay for the vision services. You say that the certificate shows that refraction is a covered benefit. You paid the required copay and your monthly premiums and expect the plan to pay for the services as defined in the certificate of benefits. The Plan denied your request. The Plan says enrollee's must receive their vision services from an in-network provider.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when you use a participating provider. We looked at the file and the Plan's rules. Vision services rendered by an out of network is not covered. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to pay for the eye exam (92014) and refraction (92015) provided January 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar sacral orthosis provided to the enrollee
You asked the Plan to pay for the orthosis. You say that The Plan denied your request. The Plan says that the billed supply code cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the orthosis. Our reviewer says that the requested orthosis is not considered medically reasonable and necessary in this case. An appropriate history and a physical examination of the back would reasonably be required to adequately assess whether the coverage criteria for an LSO have been met. The documentation does not support that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as there is no documentation of a credible physical examination of the back. There is no documentation of a covered indication such as to reduce pain by restricting mobility of the trunk, or to facilitate healing following an injury to the spine or related soft tissues, or to facilitate healing following a surgical procedure on the spine or related soft tissue, or to otherwise support weak spinal muscles and/or a deformed spine. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of the orthosis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar sacral orthosis provided to the enrollee
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the trunk repair services coded 13101 and 13102 provided.
You asked the Plan to pay for the trunk repair services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 13101 and 13102 are not supported in the medical record. Specifically, the documentation submitted does not indicate that repair, complex, trunk; 2.6 cm to 7.5 cm was performed. Therefore, code 13101 is not supported. The required primary code (13101) is denied, therefore, add-on code 13102 cannot be reimbursed separately. Based on this information, we decided that Medicare rules for coverage of the trunk repair services have not been met. Therefore, we decided that the Plan does not have to pay for the trunk repair services coded 13101 and 13102 provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for chiropractic services provided on February 22, 2019.
You asked the Plan to waive the coinsurance for chiropractic services. You say that you disagree with the denied 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 50% coinsurance for out-of-network chiropractic services. You received chiropractic services on February 22, 2019 with an out-of-network provider. Therefore, you are responsible to pay your share of the out-of-network cost-sharing charges. The allowed amount is $44.71 and 50% of that is $22.35. You have been asked to pay the total coinsurance amount of $22.35 for chiropractic services. Chiropractic services fall within the chiropractic services 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 chiropractic services provided on February 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided.
You asked the Plan to pay for the physician's services. You say that you are not required to have an authorization for residents. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.
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 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 physician's services.