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

We decided that the Plan does not have to pay for physician's services provided on June 25, 2021.
You asked the Plan to pay for the physician's services. 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. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
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 physician's services provided on June 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit (99336) rendered by the
out-of-network (OON) provider on September 24, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network
provider, without 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 provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan
does not have to pay for the domiciliary or rest home visit (99336) rendered by the out-of-network (OON)
provider on September 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for a walking boot (L4361) rendered on May 3, 2021.  You asked the Plan to waive the coinsurance for a walking boot. You say that you would like to appeal the denial. The Plan denied your request. The Plan says you were 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 20% coinsurance for Medicare-covered items for durable medical equipment (DME) and related supplies.   You have been asked to pay a $56.09 in coinsurance, which is 20% of the allowed amount for a walking boot ($280.46 allowed amount x 20% coinsurance = $56.09). A walking boot falls within the durable medical equipment (DME) and related 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 coinsurance for a walking boot (L4361) rendered on May 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (97014) provided March 1, 2021.
You asked the Plan to pay for physician services. You say that these services were medically necessary. The Plan denied your request. The Plan says the claim cannot be paid as 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 code 97014 is not supported in the medical record. Specifically, per the National Physician Fee Schedule the code billed has a status of "I" and is invalid for Medicare payment. Based on this information, we decided that Medicare rules for coverage of physician services have not been met. Therefore, we decided that the Plan does not have to pay for physician services (97014) provided March 1, 2021.
Appeal type: Home Health
Decision: Favorable

We decided that the Plan has to pay for home health services provided from June 1, 2021, through
June 24, 2021.
You asked the Plan to pay for home health services. You say that you would like payment for services provided occurring June 1, 2021, and afterward. The Plan denied your request. The Plan says that Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged. The Plan must follow Medicare rules. Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.
We looked at the file, and Medicare rules. The enrollee ended Medicare Hospice benefits on May 19, 2021. The services in question were not provided before the end of that month. Based on this information, we decided that Medicare rules for coverage of home health services have been met. Therefore, we decided that the Plan has to pay for home health services provided from June 1, 2021, through June 24, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a colonoscopy provided on September 2, 2021.
You asked the Plan to waive the copayment for a colonoscopy. You say that you were charged for a colonoscopy without being told of the additional fee if polyps were found. 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 if a screening
colonoscopy results in biopsy or removal of any growth during the procedure, the member cost share for outpatient surgery may be applied. Your contract with the Plan also clearly says that you must pay a $225 copayment for each Medicare-covered ambulatory surgical center visit. You have been asked to pay a $225 copayment for a colonoscopy. A colonoscopy 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 copayment for a colonoscopy provided on September 2, 2021.
Your complaint about lack of communication from the Plan 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81408, 81479, 81302, 81223) provided on April 1, 2021.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the out-of-network services were not pre-approved.
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 had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the service 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 lab services (81408, 81479, 81302, 81223) provided on April 1, 2021.
Appeal type: Lab
Decision: Unfavorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that providers/suppliers must report services correctly. Procedures should be reported with the Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in the Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual for Medicare Services, Chapter I(A).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. We find that CPT code 99000 is not supported in the medical record. Specifically, this code has a status indicator of "B." This means that this code cannot be paid for separately and is always bundled into payment for other services not specified. 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 laboratory services (procedure code 99000) provided to the enrollee on August 4, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for dialysis-related laboratory services provided to the enrollee on May 10, 2021.
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 claim does not meet coding standards.
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 the denied codes are not supported in the medical record. Specifically, the records clearly show that these laboratory services were related to the treatment of end-stage renal disease (ESRD). Therefore, these services cannot be reported separately by the laboratory, and are the responsibility of the dialysis center. 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 dialysis-related laboratory services provided to the enrollee on May 10, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for ultrasound services provided to the enrollee on October 12, 2021.
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 provider did not bill as required by Medicare coding regulations.
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, we have confirmed that code 76705 is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for ultrasound services provided to the enrollee on October 12, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient infusion services provided on December 17, 2020.
You asked the Plan to pay for outpatient infusion services. 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. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
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 outpatient infusion services provided on December 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for pain management services (procedure code 62320) provided to the enrollee on October 11, 2021.
You asked the Plan to pay for the services. You say that the services were billed correctly and should be paid for. The Plan denied your request. The Plan says the records are insufficient to support payment for the services.
The Plan must follow Medicare rules. Medicare rules say that in order for code 62320 to be covered, certain documentation requirements must be met. The documentation must include the legible signature of the physician or non-physician practitioner responsible for providing the care to the patient. In addition, the procedure report should clearly document the indications and the medical necessity for the blocks along with the pre and post percent pain relief achieved immediately post-injection. The medical records in this case do not meet Medicare's documentation requirements. Specifically, there is no notation of the percent of pain relief achieved either before or after the injection. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of procedure code 62320 have not been met. 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 pain management services (procedure code 62320) provided to the enrollee on October 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for injections (62320) provided October 4, 2021.
You asked the Plan to pay for the injections. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed services.
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. We looked at the file and Medicare rules. Insufficient clinical documentation was provided to support the billed service. Based on this information, we decided that Medicare rules for coverage of the injections have not been met. Therefore, we decided that the Plan does not have to pay for injections (62320) provided October 4, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (83789) provided May 27, 2021.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the billed code is not separately payable.
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 83789 is not supported in the medical record. Specifically, the billed code is inclusive to CPT code G0480 which was also billed and is not separately payable. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (83789) provided May 27, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for ultrasound services provided to the enrollee on September 24, 2021.  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 code cannot be unbundled.  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, we have confirmed that code 76856 is a column II code to column I code 93975. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for ultrasound services provided to the enrollee on September 24, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (G0482) provided December 22, 2020.
You asked the Plan to pay for the lab services. You say that the lab services are medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed 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 decided that the Plan does not have to pay for lab services (G0482) provided December 22, 2020.
You asked the Plan to pay for the lab services. You say that the lab services are medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed 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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the remote pacemaker testing you received from January 1, 2021, to October 11, 2021.
You asked the Plan to waive the copayments for the remote pacemaker testing. You say that these services were done without your personal involvement or during a visit, so there should be no copayment. The Plan denied your request. The Plan says you were charged these copayments 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 $10 copayment for diagnostic tests and procedures. You have been asked to pay a $10 copayment for the remote pacemaker testing. The remote pacemaker testing falls within the diagnostic tests and procedures benefit category. There is no requirement in your contract that diagnostic tests be done in person in order for cost sharing to apply. 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 the remote pacemaker testing you received from January 1, 2021, to October 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for lab services (G0483) provided June 9, 2021.  You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the records do not support the service 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.  In this case, the CPT Code Manual definition of code G0483 is Drug Testing, definitive laboratory results for 22 or more drug classes.  We find that CPT code G0483 is not supported in the medical record. Specifically, the records do not show results for 22 or more drug classes. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (G0483) provided June 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for neurology services provided on July 7, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the OON neurology services. You say that this provider incorrectly told you that they were in-network. The Plan denied your request. The Plan says unauthorized, non-plan care is not covered.  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 cannot be held responsible for incorrect information provided to you by an OON provider. 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 neurology services provided on July 7, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for injections (62320) provided August 2, 2021.
You asked the Plan to pay for the injections. You say that the services were medically necessary. The Plan denied your request. The Plan says the records do not support the billed services.
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. We decided that the Plan does not have to pay for injections (62320) provided August 2, 2021.
You asked the Plan to pay for the injections. You say that the services were medically necessary. The Plan denied your request. The Plan says the records do not support the billed services.
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.