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

We decided that the Plan does not have to pay for blood glucose test or reagent strips for home blood glucose monitor (A4253), lancets (A4259), calibrator solution / chips (A4256), and replacement lithium battery (A4235) provided from August 5, 2019 to October 24, 2019.
You asked the Plan to pay for blood glucose test or reagent strips, lancets, calibrator solution / chips, and replacement lithium battery. You say that the items were provided and payment should be rendered. The Plan denied your request. The Plan says the documentation provided did not include a valid proof of delivery. Therefore, coverage criteria has not 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 physician order and 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. Specifically, the delivery ticket is missing a valid signature. Therefore, we decided that the Plan does not have to pay for blood glucose test or reagent strips for home blood glucose monitor (A4253), lancets (A4259), calibrator solution / chips (A4256), and replacement lithium battery (A4235) provided from August 5, 2019 to October 24, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on May 18, 2019 by an out of network provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by a non-network provider without 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 referring provider 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 medical services provided on May 18, 2019 by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the office visit and jaw x-ray provided on May 2, 2019.
You asked the Plan to waive the copayments for the office visit and jaw x-ray. You submitted your bills for review. You say that the office did not mention additional copayments. 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 services obtained from a specialist and a $14 copayment for each Medicare-covered standard x-ray service. You have been asked to pay a $45 copayment for the office visit and a $14 copayment for the jaw x-ray. The total amount you owe is $59 ($45 + $14 = $59). The office visit falls within the "Physician/Practitioner Services, Including Doctor's Office Visits" benefit category. The jaw x-ray 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 copayments for the office visit and jaw x-ray provided on May 2, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the diabetic supplies rendered to the enrollee on August 23, 2019.
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 there is no valid proof of delivery.
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS suppliers are required to maintain proof of delivery. We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. 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 diabetic supplies rendered to the enrollee on August 23, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the shoulder, elbow, wrist, hand orthosis (SEWHO)(L3960) provided on March 19, 2019.
You asked the Plan to pay for the SEWHO. You say that the records provided should support the necessity of the services in dispute. The Plan denied your request. The Plan says there is insufficient documentation to corroborate the service that the Medicare coverage criteria has been met.
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 for the shoulder, elbow, wrist, hand orthosis (SEWHO)(L3960) provided on March 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge services rendered to the enrollee on May 8, 2019.
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 procedure code 99239 is not supported.
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 99239 is hospital discharge day management; more than 30 minutes. We find that CPT code 99239 is not supported in the medical record. Specifically, there is no documentation of more than 30 minutes of discharge services spent on the enrollee. 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 hospital discharge services rendered to the enrollee on May 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for wound care supplies provided on August 12, 2019 by an out of network provider.
You asked the Plan to pay for wound care supplies. You say to please check the attached medical records for review and reprocess the claim The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. The plan says that non-emergent services with non-contracted providers require prior-authorization prior to services being rendered.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan 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 wound care supplies provided on August 12, 2019 by the out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the diabetic supplies rendered to the enrollee from May 29, 2019 to August 17, 2019.
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 there is no valid proof of delivery.
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS suppliers are required to maintain proof of delivery. We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. 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 diabetic supplies rendered to the enrollee from May 29, 2019 to August 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the diabetic supplies rendered to the enrollee from June 4, 2019 to August 23, 2019.
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 there is no valid proof of delivery.
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS suppliers are required to maintain proof of delivery. We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. 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 diabetic supplies rendered to the enrollee from June 4, 2019 to August 23, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 17, 2019 by out of network provider.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by a non-network provider without 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 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 medical services provided on July 17, 2019 by out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the diabetic supplies rendered to the enrollee from June 5, 2019 to August 24, 2019.
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 there is no valid proof of delivery.
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS suppliers are required to maintain proof of delivery. We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. 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 diabetic supplies rendered to the enrollee from June 5, 2019 to August 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on May 30, 2019 by an out of network provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by a non-network provider without 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 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 medical services provided on May 30, 2019 by the out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the diabetic supplies rendered to the enrollee on May 31, 2019.
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 there is no valid proof of delivery.
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS suppliers are required to maintain proof of delivery. We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. 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 diabetic supplies renderedthe enrollee on May 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the echocardiography, with Doppler, provided on April 11, 2019 by the out of network provider.
You asked the Plan to pay for the physician services. The Plan denied your request. The Plan says authorization was not obtained before the services were provided to the enrollee. The Plan says that the enrollee's primary care physician did not refer them for the services. The Plan also says the services were not urgent or emergent in nature.
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 provider in this case is not a network provider with the Plan. The referring provider is not a network provider either. 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 echocardiography, with Doppler, provided on April 11, 2019 by the out of network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 27, 2019 by an out of network provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by a non-network provider without 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 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 medical services provided on August 27, 2019 by the out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on May 23, 2019 by an out of network provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by a non-network provider without 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 referring provider 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 laboratory services provided on May 23, 2019 by the out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the glucose monitor and diabetic supplies rendered to the enrollee from August 5, 2019 to October 24, 2019.
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 there is no valid physician or
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS suppliers are required to maintain proof of delivery. We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. 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 glucose monitor and diabetic supplies rendered to the enrollee on August 5, 2019 to October 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the diabetic supplies rendered from June 4, 2019 to August 23, 2019.

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 there is no valid proof of delivery.

The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS suppliers are required to maintain proof of delivery.

We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. 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 diabetic supplies rendered from June 4, 2019 to August 23, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered to the enrollee on July 9, 2019.
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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 laboratory services rendered to the enrollee on July 9, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the diabetic supplies rendered to the enrollee from July 12, 2019 to September 30, 2019.
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 there is no valid proof of delivery.
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS suppliers are required to maintain proof of delivery. We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. 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 diabetic supplies rendered to the enrollee from July 12, 2019 to September 30, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the diabetic supplies rendered to the enrollee on June 20, 2019 to September 8, 2019.
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 there is no valid proof of delivery.
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS suppliers are required to maintain proof of delivery. We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. 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 diabetic supplies rendered to the enrollee on June 20, 2019 to September 8, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the chemotherapy services provided on August 23, 2019 and September 16, 2019.You asked the Plan to waive the coinsurance for the chemotherapy services. You say that you cannot afford these injections.The Plan denied your request. The Plan says the services received have been processed correctly per your plan benefits.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 20% for Medicare Part B chemo drugs. You have been asked to pay 20% coinsurance for the chemotherapy services. The chemotherapy services fall within the Medicare Part B drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the chemotherapy services provided on August 23, 2019 and September 16, 2019.