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

We decided that the Plan does not have to waive the copayment foran office visit (99214) provided on September 18, 2019.You asked the Plan to waive the copayment foran office visit. You say that you had a doctor visit on September 18, 2019. You never had a discussion about alcohol or depression and don't understand why the charges are there.The Plan denied your request. The Plan says physician services with a primary care physician have a $5 copayment.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 physicianservices. You have been asked to pay a $5 copayment for an office visit. This servicefalls within the physician 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 foran office visit (99214) provided on September 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe glucose monitor, test strips, lancets, control solution, and lancet device provided on June 7, 2019.You asked the Plan to pay forthe glucose monitor (E0607), test strips (A4253), lancets (A4259), control solution (A4256), and lancet device (A4258). You say that the Plan should pay this claim.The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.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 proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered.Therefore, we decided that the Plan does not have to pay forthe glucose monitor, test strips, lancets, control solution, and lancet device provided on June 7, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission for the enrollee.
You asked the Plan to pre-approve these services. You say that the admission is medically necessary. The Plan denied your request. The Plan says the admission is not medically necessary.
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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the hospital on January 2, 2020 with altered mental status, failure to thrive, and weakness. She was seen for physical therapy on January 14, 2020 and was unable to participate. In occupational therapy she was dependent for bed mobility. She has skilled nursing and skilled therapy needs but does not require these services on a daily basis. As a practical matter, the enrollee does not require the necessary services on an inpatient basis at the SNF level of care. We looked at this physician's review, the file, and Medicare rules. 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 pre-approve a skilled nursing facility (SNF) admission for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the diabetic supplies provided to the enrollee from August 6, 2019 to October 25, 2019.You asked the Plan to pay for the diabetic supplies. The Plan denied your request. The Plan says that there is no valid proof of delivery.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 itemsat issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The tracking ticket does not include the items supplied and the delivery ticket does not include a tracking number to confirm it was delivered.Therefore, we decided that the Plan does not have to pay forthe diabetic supplies provided to the enrollee from August 6, 2019 to October 25, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided June 29 to June 30, 2019 by the facility.
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient services should be covered. The Plan denied your request. The Plan says the provider must resubmit the claim as observation services.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the services provided could be rendered in an outpatient observation setting. The record does not show that a stay of greater than two midnights was expected. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided June 29 to June 30, 2019 by the facility.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on October 2, 2019.
You asked the Plan to pay for the physician services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
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 services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided on October 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on September 23, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided on September 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services rendered to the enrollee on August 3, 2017.
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 was not filed timely.
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 these services was not filed until September 6, 2018. A valid waiver of liability was not received until October 7, 2019. 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 anesthesia services rendered to the enrollee on August 3, 2017.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the glucose monitor, test strips, lancets, control solution, and lancet device provided from August 14, 2019 to November 2, 2019.
You asked the Plan to pay for the glucose monitor (E0607), test strips (A4253), lancets (A4259), control solution (A4256), and lancet device (A4258). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.
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 proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered. Therefore, we decided that the Plan does not have to pay for the glucose monitor, test strips, lancets, control solution, and lancet device provided from August 14, 2019 to November 2, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the glucose monitor, test strips, lancets, control solution provided from July 31, 2019 to October 19, 2019.
You asked the Plan to pay for the glucose monitor (E2100), test strips (A4253), lancets (A4259), control solution (A4256). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.
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 proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered. Therefore, we decided that the Plan does not have to pay for the glucose monitor, test strips, lancets, control solution provided from July 31, 2019 to October 19, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CT scan provided on October 10, 2019.
You asked the Plan to waive the copayment for the CT scan. You say that you didn't realize you had a copayment. You say that your cost shouldn't be more than the Plan's. 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 $250 copayment for CT scans, MRI's, PET scans, and nuclear cardiac imaging tests. You have been asked to pay a $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 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 CT scan provided on October 10, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the psychiatric evaluation provided on July 23, 2019.
You asked the Plan to waive the copayment for the psychiatric evaluation. You say that you had no reason to go to this evaluation. 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 $40 copayment for each in-network Medicare-covered individual visit. You have been asked to pay a $40 copayment for the psychiatric evaluation. The psychiatric evaluation falls within the "Outpatient mental health care" benefit category. The medical record shows you received the psychiatric evaluation.
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 psychiatric evaluation provided on July 23, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the back brace (A9999) provided on August 29, 2019 by out of network provideR.
You asked the Plan to pay for the brace. You say that you were unaware the provider was out-of-network. The Plan denied your request. The Plan says the services at issue were non-emergent and the provider at issue is not contracted with the health plan. There was no pre-authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The 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 the back brace (A9999)
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the use of Imfinzi (durvalumab).
You asked the Plan to pre-approve Imfinzi. You say that the enrollee is at high risk for recurrent disease and needs this drug. The Plan denied your request. The Plan says the denial of authorization for Imfinzi is correct, because this drug is not supported for the enrollee's condition.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved 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 Imfinzi. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested use of Imfinzi. Our physician reviewer found Imfinzi (durvalumab) is Food and Drug Administration (FDA) approved for the treatment of unresectable Stage III non-small cell lung cancer which has not progressed following chemotherapy and radiation therapy. It is not approved for patients, such as this enrollee, with Stage II disease. Therefore, the enrollee does not meet Medicare criteria for coverage and the requested Imfinzi is not medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Imfinzi have not been met. Therefore, we decided that the Plan does not have to pre-approve the use of Imfinzi (durvalumab).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an over-the-bed table for the enrollee.You asked the Plan to pre-approve an over-the-bed table. The Plan denied your request. The Plan says that this is not covered because it is a convenience item.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 thisappeal does not serve a purpose that is primarily medical in nature. 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 pre-approvean over-the-bed table for the enrollee.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to pay for code 99202. We decided that the Plan does not have to pay for codes billed with 99225.
You asked the Plan to pay for code 99202. You say that you could not locate another Evaluation and Management (E/M) new patient visit. The patient was treated by two different specialty providers. The Plan says that another observation service was reported for the same date of service. In addition, another E/M code
was billed within a 3-year period. The Plan follows Medicare rules. Payment for an initial observation care code is for all the care rendered by the ordering physician on the date the patient's observation services began. All other physicians who furnish consultations or additional evaluations or services while the patient is receiving hospital outpatient observation services must bill the appropriate outpatient service codes. The rules also say to interpret the phrase "new patient" to mean a patient who has not received any professional services, i.e., E/M service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous 3 years.
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of codes 99225 are not met. Specifically, the record shows that another physician billed for subsequent observation care for the same dates of service at issue. The Plan has indicated that the subsequent observation care billed by the provider was approved for payment. This means that the appropriate outpatient service codes should be billed instead by all other physicians. We also decided that Medicare rules for coverage of code 99202 have been met. Specifically, we did not find the provider to be the same specialty of a previous physician billing a new patient E/M service. This means that a new patient E/M service is allowed in this case. Therefore, we decided that the Plan does not have to pay for observation care services (99225) but does have to pay for a new patient evaluation and management service (99202) provided by the provider from June 25, 2019 to June 28, 2019.
Appeal type: ER
Decision: Favorable

We decided that the Plan has to pay for the physician services provided on March 8, 2019 to March 9, 2019 by out of network provider.You asked the Plan to pay forthe physician services. You say that the services at issue were provided urgently in the Emergency room. The physician is a hospitalist assigned to the Medical Center.The Plan denied your request. The Plan says that the physician services were provided by a non-contract provider and werenot pre-authorized.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 areaurgent care and pre-approved care.The record shows the enrollee was taken to the Medical Center Emergency Room on March 8, 2019 with a complaint of pre-syncope, dizziness and vomiting. Medicare rules say the plan has to pay for care from out-of-network providers in cases involving emergencies or out of area urgent care.Therefore, we decided that the Plan has to pay forthe physician services provided on March 8, 2019 to March 9, 2019 by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on September 18, 2019.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the servicesat issue. We found no exception that would require the Plan to pay forthese services. Therefore, we decided that the Plan does not have to pay for physician's services providedon September 18, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for post-stabilization inpatient hospital services provided August 19 to August 20, 2019.You asked the Plan to pay for the post-stabilization inpatient hospital services. You say that the services at issue were medically necessary.The Plan denied your request. The Plan says the enrollee was stable for transfer to a plan facility.The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. 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 topay for the post-stabilization inpatient hospital services. 
Our reviewer says that coverage criteria has not been met for Inpatient services rendered after 4:22 PM on August 19, 2019. Our physician reviewer found as of 4:22 p.m. on August 19, 2019, the enrollee was hemodynamically and neurologically stable and appropriate for ambulance transport with monitoring to a Plan facility for continued inpatient level of care services.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 post-stabilization inpatient hospital services have not been met.Therefore, we decided that the Plan does not have to pay forpost-stabilization inpatient hospital services provided August 19 to August 20, 2019.