Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chiropractic manipulation to the extra-spinal regions (98943) mechanical traction (97012) electrical stimulation (G0283) provided September 1, 2021.
You asked the Plan to pre-approve the chiropractor. You say that you're appealing non-payment of 90712 98943 and G0283. please see attached medical notes for medical necessity. The Plan denied your request. The Plan says this service is not covered when billed by a chiropractor.
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 pre-approve chiropractic manipulation to the extra-spinal regions (98943) mechanical traction (97012) electrical stimulation (G0283) provided September 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary or rest home visit (99336) provided on April 15, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for a domiciliary or rest home visit. You say that authorization was not obtained prior to seeing this patient since it is the nursing facility's responsibility to get authorizations for their patients. You also say that it was medically necessary for the patient to receive the treatment by this provider. The Plan denied your request. The Plan says it was determined the services were not urgent or emergent and an authorization was not requested or obtained prior to services being rendered.
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 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 a domiciliary or rest home visit (99336) provided on April 15, 2021, by an out-of-network (OON) provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a face-down positioning device provided on November 2, 2021.
You asked the Plan to pay for a face-down positioning device. You say that the item at issue was a medical necessity for you. The Plan denied your request. The Plan says the item at issue is 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. It is classified as a preventive item. 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 pay for a face-down positioning device provided on November 2, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided by on August 9, 2021.
You asked the Plan to waive the copayment for an office visit. You say that you should not be charged a copayment because your primary care physician was not available. The Plan denied your request. The Plan says the proper copayment was applied for the provider that was seen.
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 $35 copayment for each Specialist visit.
You have been asked to pay a $35 copayment for an office visit. An office visit falls within the Physician/Practitioner services, including doctor's office Visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an office visit provided by on August 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye exam (92014) provided on September 18, 2021.
You asked the Plan to waive the copayment for the eye exam. You say that this was a routine exam and should have no copayment. The Plan denied your request. The Plan says this claim was processed correctly, and your copayment was assessed in accordance with your contract. The eye exam in question was billed with a medical diagnosis and the medical records indicate that the exam was medical in nature rather than routine.
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 outpatient physician services for the diagnosis and treatment of diseases and injuries of the eye. You have been asked to pay a $10 copayment for the eye exam. The eye exam was billed with a medical diagnosis, and the medical records provided indicate that this exam was provided for medical evaluation. This service therefore is considered an outpatient physician service for the diagnosis and treatment of diseases and injuries of the eye. This means that you have been asked to pay the correct amount based on your contract with
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the eye exam (92014) provided on September 18, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for laboratory services (88305) provided on October 5, 2020.
You asked the Plan to pay for laboratory services. You say that your other insurance was not active on this date of service. The Plan denied your request. The Plan says that an explanation of benefits is needed from your primary insurance.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. The Plan has not met its obligation with regards to coordination of benefits. The submitted documentation does not show that the Plan has sent the bill to the primary insurer or instructed the provider to do so. Therefore, we decided that the Plan has to pay for laboratory services (88305) provided on October 5, 2020.
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the transportation of portable x-ray equipment (R0075) provided on August 25, 2021.
You asked the Plan to pay for the transportation of portable x-ray equipment. You say that this was necessary. The Plan denied your request. The Plan says this was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that the technical component of a portable x-ray service during the course of a Medicare-covered stay in a skilled nursing facility (SNF), representing the procedure itself, including any associated transportation and setup costs, would be subject to consolidated billing (the SNF "bundling" requirement for services furnished to the SNF's Part A residents), and must be included on the SNF's Part A bill for the resident's covered stay rather than being billed separately under Part B. We looked at the file and Medicare rules. The service at issue was provided to a SNF resident and must be billed on the SNF bill. Based on this information, we decided that Medicare rules for coverage of the transportation of portable x-ray equipment have not been met. Therefore, we decided that the Plan does not have to pay for the transportation of portable x-ray equipment (R0075) provided on August 25, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on July 27, 2021.
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 the testing is not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on July 27, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy provided by a participating provider on July 19, 2021.
You asked the Plan to waive the copayment for physical therapy. You say that you would like the Plan to pay for these copayments. 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 $35 copayment for outpatient rehabilitation services/in-network. You have been asked to pay a $35 copayment for physical therapy. The correct copayment has been applied to the services that were provided. Physical therapy falls within the outpatient rehabilitation services/in-network 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 physical therapy provided by a participating provider on July 19, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) provided on July 3, 2021.
You asked the Plan to pay for the ambulance service. You say that you were feeling sick and dizzy. You say that you were afraid to ride the bus home. You say that the you decided you did not need the ambulance after your vitals were checked. You also say that you were not aware you could be charged for not taking the ambulance and feel they should not be charged. The Plan denied your request. The Plan says there was no transport provided on the date of service. The Plan also says that since no transport was provided, there is no payable service.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on July 3, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) provided on July 3, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services rendered from April 27, 2020 to April 30, 2020.
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 the submitted records do not support the billing of secondary diagnosis J96.01.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services provided with secondary diagnosis J96.01 (acute respiratory failure with hypoxia). 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 these services. Our reviewer says that the submitted records do not support the billing of secondary diagnosis J96.01. Our physician reviewer found the records support an admission for further evaluation and treatment of pneumonia. On presentation, the enrollee was reported to have nausea and vomiting, and physical exam findings included, skin warm and dry, normal pulmonary effort, without stridor or respiratory distress. An arterial blood gas obtained on room air demonstrated complete compensation with normal PH and PCO2 levels. Supplemental oxygen was administered via nasal cannula, and intravenous antibiotics were initiated. The records do not support the billing of secondary diagnosis J96.01. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services rendered from April 27, 2020 to April 30, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary visit provided on April 12, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the domiciliary visit. You say that the provider relies on the facility staff to verify eligibility and obtain authorization. You say the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.
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 item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for a domiciliary visit provided on April 12, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on January 8, 2021.
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 the services were not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on January 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an urgent care visit provided on September 27, 2021.
You asked the Plan to waive the copayment for the urgent care visit. You say that you went in for a coronavirus booster shot but the provider informed you that they did not offer that service. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $65 copayment for each urgent care visit. The record shows you were seen and evaluated at the hospital on September 27, 2021. Therefore, you have been asked to pay a $65 copayment for the urgent care visit. The urgent care visit falls within the Urgently Needed 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 copayment for an urgent care visit provided on September 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for foot orthotics.
You asked the Plan to reimburse you for foot orthotics. You say that you would like reconsideration for the reimbursement of your fitted orthotics. The Plan denied your request. The Plan says an itemized bill is needed to process this claim.
Medicare rules state the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.
We looked at your request, the file and Medicare rules. Based on this information we have determined that the Medicare criteria for coverage of the foot orthotics have not been met. Specifically, there is insufficient information to validate what specific equipment was provided. Without this information, we are unable to determine the CPT code that would be associated with this equipment, if payment is due or the amount of payment. Therefore, we decided that the Plan does not have to reimburse you for foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services provided to the enrollee on September 18, 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 70544 is a column II code to column I code 70551. 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 imaging services provided to the enrollee on September 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit and does not have to waive the coinsurance for Medicare Part B drugs provided on August 23, 2021.
You asked the Plan to waive the copayment for a specialist visit and to waive the coinsurance for Medicare Part B drugs. You say that you were told that the services would be fully covered. 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 $40 copayment for specialist visits. Your contract with the Plan also clearly says that you must pay 20%
coinsurance for Medicare Part B prescription drugs. You received a specialist visit on August 23, 2021. Therefore, you are responsible to pay the $40 copayment. You received Medicare Part B drugs on August 23, 2021. The total allowed amount is $1,003.29 and 20% of that is $200.66. The total amount you owe is: $240.66. You have been asked to pay the total amount of $240.66 for a specialist visit and Medicare Part B drugs. A specialist visit falls within the physician/practitioner services, including doctor's office visits benefit category. Medicare Part B drugs fall 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 copayment for a specialist visit and does not have to waive the coinsurance for Medicare Part B drugs provided on August 23, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the transportation of portable x-ray equipment (R0075) provided on August 3, 2021.
You asked the Plan to pay for the transportation of portable x-ray equipment. You say that this was necessary. The Plan denied your request. The Plan says this cannot be paid as billed.
The Plan must follow Medicare rules. Medicare rules say that the technical component of a portable x-ray service during the course of a Medicare-covered stay in a skilled nursing facility (SNF), representing the procedure itself, including any associated transportation and setup costs, would be subject to consolidated billing (the SNF "bundling" requirement for services furnished to the SNF's Part A residents), and must be included on the SNF's Part A bill for the resident's covered stay rather than being billed separately under Part
B. We looked at the file and Medicare rules. The service at issue was provided to a SNF resident and must be billed on the SNF bill. Based on this information, we decided that Medicare rules for coverage of the transportation of portable x-ray equipment have not been met. Therefore, we decided that the Plan does not have to pay for the transportation of portable x-ray equipment (R0075) provided on August 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral exam (D0120) and prophylaxis (D1110) provided on July 25, 2021.
You asked the Plan to pay for the dental services. You say that you were not aware that you had dental coverage. You say that you had dental coverage previously but dropped it due to the monthly cost. You also say that since you were not paying for dental coverage you though you no longer had any. The Plan denied your request. The Plan says [Enter plan denial rationale, e.g. "...rules for SNF care have not been met."]
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for the dental services was not filed until October 1, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the oral exam (D0120) and prophylaxis (D1110) provided on July 25, 2021