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

 We decided that the Plan does not have to pay for the laboratory services (87486, 87496, 87498, 87541, 87581, 87631, 87640, and 87798) provided on October 6, 2020.  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 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 claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in a skilled nursing facility setting. Therefore, we decided that the Plan does not have to pay for the laboratory services (87486, 87496, 87498, 87541, 87581, 87631, 87640, and 87798) provided on October 6, 2020.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the breast ultrasound you had on July 24, 2021  You asked the Plan to waive the copayment for the breast ultrasound. You say that your doctor told you that you needed a yearly breast exam. You say that they did a mammogram and ultrasound, but you didn't ask for the ultrasound. You said that your doctor didn't say anything about an ultrasound. 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 $60 copayment for ultrasounds.    You have been asked to pay a $60 copayment for the breast ultrasound. This copayment applies regardless of the reason for the 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 breast ultrasound you had on July 24, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the therapy services (97530) provided on August 19, 2020.  You asked the Plan to pay for code 97530. 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 the services of an OTA shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of occupational therapy have not been met. Specifically, the billing provider is a nurse practitioner, and not a licensed therapist. As such, OTA services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for the therapy services (97530) provided on August 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a standard wheelchair (K0001).  You asked the Plan to pre-approve a standard wheelchair. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says rules for out-of-area care have not been met.  Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care.    We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a standard wheelchair have not been met. Specifically, the requested standard wheelchair has been ordered for delivery to a location outside the Plan's service area. Therefore, we decided that the Plan does not have to pre-approve a standard wheelchair (K0001).
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to pay for an office visit and related services (99214, J0702, 20610, 73562) provided on December 27, 2019.  You asked the Plan to pay for an office visit and related services. You say that you were dropped from your spouse's plan so this should be paid. The Plan denied your request. The Plan says that an explanation of benefits from your primary plan is needed before this claim can be paid.  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. Specifically, while the Plan has contacted the primary insurer to request the claim, they have not billed the primary insurer or directed the provider to bill the primary insurer. Therefore, we decided that the Plan has to pay for an office visit and related services (99214, J0702, 20610, 73562) provided on December 27, 2019.   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: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that IRF services are medically necessary. The Plan denied your request. The Plan says based on Medicare guidelines, your request for approval of an IRF admission does not meet the requirements for approval.  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.  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 pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.   Our physician reviewer found that the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the prophylaxis (D1110), and periodic oral evaluation (D0120), provided on July 15, 2021.  You asked the Plan to pay for the prophylaxis and oral evaluation. You say that the services should be covered. The Plan denied your request. The Plan says you have exhausted the Plan benefits for these services.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the prophylaxis (D1110), and periodic oral evaluation (D0120), provided on July 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the outpatient office visit provided March 3, 2021.  You asked the Plan to pay for the office visit. You say that please find copies of your letter to the provider indicated that you never had the blood tests. So their charges are not valid. The Plan should get refunded if already paid for these tests. The Plan denied your request. The Plan says an itemized bill was requested from the provider but was not received.  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, an itemized bill was requested from the provider but was not received. The provider has been informed that the service was billed incorrectly. Based on this information, we decided that Medicare rules for coverage of the office visit have not been met. Therefore, we decided that the Plan does not have to pay for the outpatient office visit provided March 3, 2021.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to change the denial for the skin sealants and incontinence garment provided on May 16, 2021.  You asked the Plan to change the denial for the skin sealants and incontinence garment. You say that the claim billed both codes with modifier GY because they are non-covered services and should be denied as such. You say that the claim should be reprocessed in support of this request. The Plan denied your request. The Plan says Original Medicare is responsible for payment.  Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicarehe 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 change the denial for the skin sealants and incontinence garment provided on May 16, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the non-emergency wheelchair van transport provided on February 11, 2021.  You asked the Plan to pay for the transportation service. You say that you have no money to pay for this. The Plan denied your request. The Plan says wheelchair van transportation is not covered even if provided by an ambulance company.  The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport services.   The services you have asked the Plan to pay for are wheelchair van transport services. Therefore, we decided that the Plan does not have to pay for the non-emergency wheelchair van transport provided on February 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for therapeutic activities, direct (one on one) patient contact by the provider (97530) provided November 2, 2020.  You asked the Plan to pay for therapeutic activities. You say that please find the attached medical records required to reprocess the denied claim. The Plan denied your request. The Plan says the code is not appropriate for 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 97530 is therapeutic activities, direct (one on one) patient contact by the provider (use of dynamic activities to improve functional performance), each 15 minutes.  We find that CPT code 97530 is not supported in the medical record. Specifically, the medical records indicate that skilled services by a COTA (Certified Occupational Therapy Assistant) visit for management and evaluation of the plan of care in a home health setting was performed. There is a more appropriate code that should be used for the procedure performed. Based on this information, we decided that Medicare rules for coverage of therapeutic activities have not been met. Therefore, we decided that the Plan does not have to pay for therapeutic activities, direct (one on one) patient contact by the provider (97530) provided November 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the primary care office visit you had on March 25, 2021.  You asked the Plan to waive the copayment for the primary care office visit. You say that this was your annual wellness visit, so there should be no copayment. The Plan denied your request. The Plan says you received services in excess of an annual physical, so the copayment applied 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 $5 copayment for primary care provider services.   Your contract states that an annual wellness visit includes services to develop or update a personalized prevention plan based on your current health or risk factors.  There is no cost sharing for an annual wellness visit.  However, applicable cost sharing will apply to any non-preventive services you receive during this visit.  We looked at the medical records from this visit to determine if you received services beyond an annual wellness visit. The records show that you were evaluated for breast pain (and provided a referral for a mammogram as a result). You also discussed back and knee pain and requested a new pain medicine for this condition. These services are beyond the scope of an annual wellness visit, which is why the primary care cost sharing applies. 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 primary care office visit you had on March 25, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for the urinary leg or abdomen bag (A4358) Bedside drainage bag (A4357) and insertion tray with drainage bag with indwelling catheter (A4314) provided July 12, 2021.  You asked the Plan to pay for the medical supplies. You say that the claim denied as payment included for another service. You have never received payment for any services for this enrollee. Per Medicare, the billed services are covered. The Plan denied your request. The Plan says the supplies would be considered a part of the skilled nursing facility bundled billing.  The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.   Records show that the medical supplies was used in a SNF or hospital. Therefore, we decided that the Plan does not have to pay for the urinary leg or abdomen bag (A4358) Bedside drainage bag (A4357) and insertion tray with drainage bag with indwelling catheter (A4314) provided July 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for endodontic therapy (D3310) provided by an out-of-network provider on June 30, 2021.  You asked the Plan to pay for endodontic therapy. You say that you were never told that you needed to inquire about the dentist being in-network. The Plan denied your request. The Plan says these services were provided by an out-of-network provider; therefore, this claim has been correctly processed.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit when provided by an out-of-network provider. Therefore, we decided that the Plan does not have to pay for endodontic therapy (D3310) provided by an out-of-network provider on June 30, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for ambulance services provided on July 12, 2021.  You asked the Plan to waive the copayment for ambulance services. You say that you do not think you should 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 $280 copayment for ambulance services.  You have been asked to pay a $280 copayment for ambulance services. Ambulance services fall within the ambulance 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 ambulance services provided on July 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the emergency room and inpatient services provided from June 12, 2018, to June 15, 2018.  You asked the Plan to pay for the emergency room and inpatient services. You say that you were advised on April 28, 2021, by a plan representative that the claim had been paid on August 3, 2018. You also say that the services were medically necessary and should be paid. The Plan denied your request. The Plan says the corrected claims for the dates of service in this case were received after the 12-month time frame.  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 emergency room and inpatient services was not filed until June 2, 2021, and August 23, 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 emergency room and inpatient services provided from June 12, 2018, to June 15, 2018.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from April 24, 2021, to April 29, 2021.  You asked the Plan to waive the copayment for inpatient hospital care. You say that you disagree with the charges because you have never been charged in the past. 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 $275 copayment for days 1-5 for inpatient hospital care.   You received inpatient hospital care from April 24, 2021, to April 29, 2021. Therefore, you are responsible to pay a $275 copayment for day 1-5 (April 24, 2021, to April 28, 2021). The total amount you owe is: $275 (copayment) x 5 (inpatient days) = $1,375.  You have been asked to pay the total copayment amount of $1,375 for inpatient hospital care. Inpatient hospital care falls within the inpatient hospital care 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 inpatient hospital care provided from April 24, 2021, to April 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the core build up (D2950) and crown (D2740, provided on July 27, 2021.  You asked the Plan to pay for the core build up and crown. You say that the service should be covered. The Plan denied your request. The Plan says the cost share was applied correctly.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the core build up (D2950) and crown (D2740, provided on July 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory testing provided on June 29, 2021.  You asked the Plan to pay for lab testing. You say that your lab performed the tests requested by the ordering physician. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because screening testing is not covered by Medicare.  The Plan must follow Medicare rules. Medicare rules say that a physician order or clear to intent to order specific lab services is required for covered lab services.   We looked at the file and Medicare rules. The documentation submitted does not include a physician order or clear intent to order the specific lab services billed on this claim. Without a lab order, it cannot be determined that this lab testing was ordered for Medicare-covered purposes. Based on this information, we decided that Medicare rules for coverage of lab testing have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on June 29, 2021.