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

We decided that the Plan does not have to pay for home health services provided to the enrollee from January 1, 2020, to July 21, 2020.
You asked the Plan to pay for these services. You say that you were told these services would be covered by the Plan. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network home health 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 Plan contract specifically states home health care requires prior authorization both in and out of network.
The 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 home health services provided to the enrollee from January 1, 2020, to July 21, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services ($301) provided to on June 15, 2021.
You asked the Plan to pay for these services. You say that these services should be covered by the Plan as they
were necessary after hip surgery. The Plan denied your request. The Plan says those services not directly
related to manual manipulation of the spine are not covered.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not
manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for chiropractic
services ($301) provided to on June 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second opinion visit to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve second opinion visit. You say that your treating surgeon conferred with others in the Plan network and none had performed your needed surgery, so you are requesting a second outside opinion. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this provider is out-of-network with the Plan and you can receive a second opinion visit from an in-network orthopedic specialist.
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 a second opinion visit to be provided by an out-of-network (OON) provider
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xenical, 120 mg capsule.
You asked the Plan to pre-approve Xenical. You say that the enrollee is taking this medication along with focusing on a healthy diet and exercise. The Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not covered under Medicare Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Xenical, 120 mg capsule
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on May 25, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for office visit. You say that there was valid authorization for this visit. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and authorization was not 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 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 an office visit provided on May 25, 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 two pairs of diabetic shoes purchased March 29, 2021.
You asked the Plan to pay for these shoes. You say that you believe these shoes should be covered by the Plan.
The Plan denied your request. The Plan says these shoes were purchased from a provider who is both out of
network and who is not a Medicare eligible provider. The Plan states one pair of shoes will be covered as a
courtesy; however, the Plan will not pay for both pairs.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary
for items provided directly by a vendor who is not a Medicare eligible provider. These shoes were purchased
out of network from a provider is not a Medicare eligible provider. While the Plan has agreed to pay for one
pair of shoes, they are not required to do so as you did not follow your Plan contract rules when purchasing
these shoes. Therefore, we decided that the Plan does not have to pay for two pairs of diabetic shoes purchased
on March 29, 2021
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the acute inpatient rehabilitation care provided from June 11, 2021, through June 16, 2021.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the services provided.
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 $200 copay each day, for days 1-5 for inpatient hospital care.
You have been asked to pay $1000 ($200 copayment x 5 days) for the acute inpatient rehabilitation care provided. 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 acute inpatient rehabilitation care provided from June 11, 2021, through June 16, 2021.
Appeal type: Surgery
Decision: Partially Favorable

We decided that the Plan has to waive the coinsurance for the diagnostic mammogram. We decided that the Plan does not have to waive the copayment for the aspiration.
You asked the Plan to waive the cost sharing for the mammogram and aspiration. You say that you had no choice about the follow up appointment or the aspiration. You also say the procedure was not a surgery. The Plan says that you have been charged the correct cost sharing amount.
We decided that the Plan has to waive the coinsurance for the diagnostic mammogram. The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Coinsurance is a percentage of the allowed amount for an item or service. The Plan has not shown what the allowed amount is for the diagnostic mammogram. We are unable to determine whether you were charged the correct coinsurance amount. Therefor, we decided that the Plan must waive the coinsurance for the mammogram.
We also decided that the Plan does not have to waive the copayment for the aspiration.
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 also clearly says that you must pay a $150 copayment for outpatient hospital surgery services.
The service you received is considered a surgical service. You have been asked to pay a $150 copayment for the aspiration. The aspiration falls in 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 waive the copayment for the aspiration.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hematology and oncology services to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve OON services. You say that it is very important for you to receive a second opinion. The Plan denied your request. The Plan says there are in-network providers available 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 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve hematology and oncology services 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 copayment for the wound debridement procedure you had at an outpatient hospital facility on August 2, 2021.
You asked the Plan to waive the copayment for the wound debridement procedure. You say that you do not think this was billed correctly. You said that this visit was for wound care, not for any type of surgery. The Plan denied your request. The Plan says you were charged this copayment 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 $350 copayment for outpatient surgery in an outpatient hospital facility.
You have been asked to pay a $350 copayment for the wound debridement procedure. Medicare considers wound debridement to be a surgical service. 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 wound debridement procedure you had at an outpatient hospital facility on August 2, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the hand surgery provided on May 28, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the hand surgery. You say that the service is 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 the hand surgery provided on May 28, 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 the injection and guidance services rendered on April 26, 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 claim is a duplicate.
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the Plan on a separate claim for the same date of service. 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 injection and guidance services rendered on April 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for out of network services provided to the enrollee on June 28, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must 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 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 out of network services provided to the enrollee on June 28, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided the Plan does not have to pay for an oxygen concentrator purchased on February 17, 2021.
You asked the Plan to pay for this equipment. You say that you rented equipment that was defective and chose to buy your own. The Plan denied your request. The Plan says oxygen equipment is only covered by Medicare on a rental basis. Outright purchase of oxygen equipment is not covered.
Medicare rules say that plans can require enrollees to get care from network providers and can require enrollees to get prior authorization. The Plan contract says that enrollees must use Plan providers and that durable medical equipment requires prior authorization. This oxygen concentrator was purchased out of network, without prior authorization. You did not follow your Plan contract rules when you purchased this equipment. We found no exception that would require the Plan to pay for this equipment. Therefore, we decided that the Plan does not have to pay for an oxygen concentrator purchased on February 17, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on May 27, 2021.
You asked the Plan to pay for the 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 covered.
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 regard to the physician's intent that the test be performed prior to services taking place. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on May 27, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department visit (99284) provided on March 3, 2021.
You asked the Plan to pay for the emergency department visit. 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 covered.
The Plan must follow Medicare rules. Medicare does not pay for services provided to enrollees in custody under a penal statute unless certain criteria are met. We looked at the file and Medicare rules. The file shows that the enrollee was in custody at the time these services were provided as evidenced by the medical records. Medicare payment may not be made for these services. Therefore, we decided that the Plan does not have to pay for the emergency department visit (99284) provided on March 3, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the pneumatic compression device and supplies (codes E0675 and E0673) provided on April 2, 2021.
You asked the Plan to pay for the pneumatic compression device and supplies. You say that this device is medically necessary for this patient and it is not considered experimental/investigational. The Plan denied your request. The Plan says this specific device is not a covered benefit.
The Plan must follow Medicare rules. pneumatic compression devices coded as E0675 are not covered by Medicare. In addition, the rules say that E0673 is only covered when billed with a covered pneumatic compression device. Because E0675 is not a covered device, this supply is not covered either. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the pneumatic compression device and supplies have not been met.
Therefore, we decided that the Plan does not have to pay for the pneumatic compression device and supplies (codes E0675 and E0673) provided on April 2, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee on March 26, 2021 and billed under codes 99601 and 99602.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare guidance says procedure codes 99601 and 99602 have a status code of "I". Medicare guidance says status code "I" = Not valid for Medicare purposes. Medicare uses another code for reporting of and payment for these services".
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes.
In this case, the codes billed have a status indicator preventing payment on Medicare claims. 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 home health services provided to the enrollee on March 26, 2021 and billed under codes 99601 and 99602.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for a second unit of 93320 (doppler echocardiography) billed for
date of service April 7, 2021.
You asked the Plan to pay for the second unit of 93320. You say that you have provided all medical records
and this claim should be paid in full. The Plan denied your request. The Plan says it has re-reviewed the
medical records and has paid for all of the services billed except for the second unit of 93320. The Plan says
that the medical records only support one unit of this code.
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, you billed two units of Doppler echocardiography for date of service April 7, 2021. The medical
records show that the patient had a transesophageal echocardiogram with doppler at 10:53pm on April 7, 2021.
There is only one record showing this one echocardiogram for this date of service. You did provide records
showing that the patient had a second echocardiogram, but that second one did not occur until April 24, 2021.
Based on the medical records, a second unit of code 93320 is not supported in the medical record.
Based on this information, we decided that Medicare rules for coverage of the second unit of 93320 have not been met. Therefore, we decided that the Plan does not have to pay for a second unit of 93320 (doppler echocardiography) billed for date of service April 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services (99153) provided on June 10, 2021.
You asked the Plan to pay for code 99153. 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 covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
We looked at the file and Medicare rules. In this case, the review shows that the medical records provided represent professional charges; however, procedure code 99153 was provided in a facility. Procedure code 99153 has a PC/TC Modifier Status of 3, which specifies a Technical Component only code. Therefore, we decided that the Plan does not have to pay for the moderate sedation services (99153) provided on June 10, 2021.