Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe knee orthosis (L1833) provided October 11, 2019.You asked the Plan to pay forthe orthosis. You say that say the medical records provided support the necessity of the services in dispute.The Plan denied your request. The Plan says there is insufficient documentation to corroborate the service so that the Medicare coverage criteria has been met.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid delivery ticket and proof of delivery for the supplies provided in this case.  The delivery ticket submitted did not include the carriers tracking number and the proof of delivery did notinclude an order number or details to corroborate the delivery ticket submitted.Therefore, we decided that the Plan does not have to pay forthe knee orthosis (L1833) provided October 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foran injection provided on September 19, 2019 by an out of network (OON) provider.You asked the Plan to pay foran injection. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that there are multiple in-network providers available for these services within 30 miles of the member's residence.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay foran injection provided on September 19, 2019 by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ED visit provided on September 29,
2019.
You asked the Plan to waive the copayment for the ED visit. You say that you collapsed and fell on concrete.
You say that you needed to go to the emergency room. The Plan denied your request. The Plan says 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 $90
copayment for emergency services in an emergency room.
You have been asked to pay a $90 copayment for the ED visit. The ED visit falls within the "Emergency care"
benefit category. The records show that you were treated in the emergency department. 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 ED visit provided on September 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for moderate sedation services (99152 and 99153) provided on June 13, 2019.
You asked the Plan to pay for the moderate sedation services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted did not include documentation of the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status. Additionally, the documents submitted and claim form indicate this procedure was performed in a facility place of service of 21. Payment for this service is included in payment to the facility and not separately reimbursable for this provider in this place of service.
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 99152 is moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older. The CPT Code Manual definition of code 99153 is moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List separately in addition to code for primary service).
We find that CPT codes 99152 and 99153 are not supported in the record. Specifically, the record does not indicate the presence of an independent trained observer. Additionally, 99153 is a "technical only" code and Medicare considers that the independent trained observer represents an expense to the facility and may only be billed by the facility. Based on this information, we decided that Medicare rules for coverage of the moderate sedation services have not been met. Therefore, we decided that the Plan does not have to pay for moderate sedation services (99152 and 99153) provided on June 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on October 4, 2019.
You asked the Plan to waive the copayment for the office visit. You say that this should be included in the surgery copayment. The Plan denied your request. The Plan says 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 $10 copayment per visit for a primary care physician. You have been asked to pay a $10 copayment for the office visit. The 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 the office visit provided on October 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the office visit, ophthalmoscopy and eye ultrasound provided on July 15, 2019.

You asked the Plan to waive the copayments for the office visit, ophthalmoscopy and eye ultrasound. You say that you scheduled a routine eye exam. You say that the charges should be removed. The Plan denied your request. The Plan says the copayments 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 $45 copayment for each covered specialist office visit, a $90 copayment for each covered diagnostic procedure or test at a network doctor's office and a $150 copayment for covered diagnostic radiology services in a provider's office or freestanding radiology center. 

You have been asked to pay a total of $124.59 for the office visit, ophthalmoscopy and eye ultrasound. 

Service	Allowed Amount	Standard Copayment	Member Liability
The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The ophthalmoscopy and eye ultrasound fall within the "Outpatient diagnostic tests and therapeutic services and 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 copayments for the office visit, ophthalmoscopy and eye ultrasound provided on July 15, 2019. 
Office Visit	$149.05	$45	$45
Ophthalmoscopy	$50.08	$90	$50.08
Eye Ultrasound	$29.51	$150	$29.51
TOTAL:			$124.59
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe office visit provided on June 6, 2019 by an out of network (OON) provider.Youasked the Plan to pay forthe office visit. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services rendered are not a covered benefit.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe office visit provided on June 6, 2019 by an out of network (OON) provider
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CT scan provided on September 3, 2019.You asked the Plan to waive the copayment for the CT scan. You say that you weren't aware of the cost for additional services or tests. You say that this should be covered in full.The Plan denied your request. The Plan says 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $250 copayment for Medicare-covered diagnostic radiology services.The enrollee has been asked to pay $234.97, which is less than the standard $250 copayment for the CT scan. The CT scan falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the CT scan provided on September 3, 2019
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued SNF services after November 24, 2019.You asked the Plan to pre-approve the SNF services. You say that the continuation of SNF services is medically necessary.The Plan denied your request. The Plan says the member's condition is such that a sage and appropriate discharge to a lower level of care is warranted.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in an SNF setting.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF services have not been met.Therefore, we decided that the Plan does not have to pre-approve continued SNF services after November 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveblood glucose testing strips with supply code A4253.You asked the Plan to pre-approveblood glucose testing strips. You say that you feel that these supplies are medically necessary.The Plan denied your request. The Plan says the denial of authorization for these supplies is correct, because you have already been approved for a continuous glucose monitor with supplies, so these additional supplies are not covered by Medicare.The Plan must follow Medicare rules. Medicare rules say that if a continuous glucose monitor device and supplies are approved, then additional standard testing strips will be denied as non-covered. We looked at the file and Medicare rules. You have already been approved for a continuous glucose monitor and supplies; therefore, these additional testing supplies are not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of blood glucose testing strips have not been met.Therefore, we decided that the Plan does not have to pre-approveblood glucose testing strips with supply code A4253.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveDiclofenac Gel 3%.You asked the Plan to pre-approveDiclofenac Gel 3%. You say that the requested medication is necessary.The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administereddrugs. 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-approveDiclofenac Gel 3%.Benefits for Diclofenac Gel 3%may be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ondansetron.You asked the Plan to pre-approve Ondansetron. You say that you would like the plan to reconsider their denial The Plan denied your request. The Plan says the requested drug is not a covered benefit.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 Ondansetron.Benefits for Ondansetronmay be available under Medicare Part D.Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the apixaban, vitamin C, furosemide, fenofibrate, atorvastatin, amiodarone, amlodipine, carvedilol, lisinopril, vitamin B-12, potassium chloride, aspirin, isodorbide mononitrate ER and tamsulosin provided on September 25, 2019 through September 26, 2019.
You asked the Plan to pay for these drugs. The Plan denied your request. The Plan says that these drugs are not covered under 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 pay for the apixaban, vitamin C, furosemide, fenofibrate, atorvastatin, amiodarone, amlodipine, carvedilol, lisinopril, vitamin B-12, potassium chloride, aspirin, isodorbide mononitrate ER and tamsulosin provided on September 25, 2019 through September 26, 2019.
Benefits for these drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lumbar-sacral orthosis provided on August 14, 2019.You asked the Plan to pay for the lumbar-sacral orthosis. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plansays the services billed are not supported by the documentation.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay forthe lumbar-sacral orthosis provided on August 14, 2019.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has pre-approval for continued SNF services after January 23, 2020.You asked the Plan pre-approval forSNF care. You say that the enrollee has had a decline in health. You also say that you are asking the Plan to cover the enrollee due to new medications and diagnosis.The Plan denied your request. The Plan says that the enrollee does not need daily skilled nursing care. The Plan also says that the records show that the enrollee refused both physical and occupational therapies and has been discharged from therapy.The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before the last covered day. This notice must include a description of the enrollee's right to an appeal.We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or more days before January 23, 2020. The Plan must pay for SNF services until the 100-day SNF care benefit is exhausted or daily skilled care is no longer needed and proper notice is issued.Therefore, we decided that the Plan has pre-approval forcontinued SNF services after January 23, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Yescarta (CAR-T cell therapy) for the enrollee.
You asked the Plan to pre-approve Yescarta. The Plan denied your request. The Plan says that the appeal information did not indicate any literature support for repeat CAR-T therapy.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Yescarta. Our reviewer says that Yescarta is not medically reasonable and necessary for the enrollee in this case. Yescarta is not FDA-approved for the enrollee's diagnosis. The use of Yescarta is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. Yescarta is not safe in CAR-T cell associated with significant toxicities in repeated doses that can be life threatening. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of Yescarta We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Yescarta have not been met. Therefore, we decided that the Plan does not have to pre-approve Yescarta (CAR-T cell therapy) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee on September 16, 2019.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the non-urgent services are not authorized because the providers are non-network providers, and a non-network provider referred the member.
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 non-urgent services are not authorized because the providers are non-network providers The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the services provided to the enrollee on September 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for long-term care provided on September 27, 2019 by an out of
network (OON) provider.
You asked the Plan to pay for long-term care. You say that these services were medically necessary. The Plan
denied your request. The Plan says prior authorization was not obtained for the services in question.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for long-term care provided on September 27, 2019
by an out of network (OON) provider.