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

We decided that the Plan does not have to pay for vertebral corpectomy (63091x2) provided on July 1, 2019.
You asked the Plan to pay for the vertebral corpectomy. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the submitted documentation does not support the services 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 63091x2 is vertebral corpectomy (vertebral body resection), partial or complete, transperitoneal or retroperitoneal approach with decompression of spinal cord, cauda equina or nerve root(s), lower thoracic, lumbar, or sacral; each additional segment (List separately in addition to code for primary procedure). We asked our coder 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 the vertebral corpectomy. Our reviewer says that the billing of CPT code 63091x2 is not supported by the medical record. Our reviewer found the documentation does not note what was decompressed and the documentation does not clearly describe the second procedure.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the vertebral corpectomy have not been met. Therefore, we decided that the Plan does not have to pay for vertebral corpectomy (63091x2) provided on July 1, 2019.
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 the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the enrollee's medical status requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional therapy of physical therapy (PT) and occupational therapy (OT) but the enrollee's functional status does not require this on an intensive rehabilitation facility therapy program level 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for discharge day management (99238) provided on May 24, 2019. You asked the Plan to pay for discharge day management. You say that this should be covered. The Plan denied your request. The Plan says this code is not supported by the records. 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 99238 is hospital discharge day management; 30 minutes or less. We find that CPT code 99238 is not supported in the medical record. Specifically, this is a time-based code and the records do not contain documentation of the time spent on this service. Furthermore, there is documentation of discharge services on two different dates. Based on this information, we decided that Medicare rules for coverage of discharge day management have not been met. Therefore, we decided that the Plan does not have to pay for discharge day management (99238) provided on May 24, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for molecular genetic hereditary predictive screening testing provided to the enrollee on September 30, 2019.You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. The Plan says Medicare says tests with no relation to a medical diagnosis of disease for the health of the patient are not a benefit. The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are 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 pay for the testing. Our reviewer says that the testing at issue in this case is not medically reasonable or necessary. Our physician reviewer found Cxbladder testing measures five mRNA biomarkers that are found in the urine. The role of biomarkers in the management of suspected bladder cancer is not firmly established. Further prospective, randomized clinical trials are needed to establish whether such testing is medically reasonable and 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 the testing have not been met. Therefore, we decided that the Plan does not have to pay for molecular genetic hereditary predictive screening testing provided to the enrollee on September 30, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for self-care training (97535) and therapeutic activities (97530) provided on July 2, 2019.You asked the Plan to pay for the self-care training and therapeutic activities. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the services that have been 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 (use of dynamic activities to improve functional performance), each 15 minutes.The CPT Code Manual definition of code 97535 is self-care/home management training (eg, activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment) direct one-on-one contact, each 15 minutes. We asked our coder 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 the self-care training and therapeutic activities. Our reviewer says that CPT code 97535 does not meet criteria for billing or reimbursement consideration. The medical records provided do not include documentation detailing total time spent providing Self-care/home management training (eg, activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment) direct one-on-one contact, each 15 minutes, therefore, the service cannot be validated. Our reviewer found CPT code 97530 does not meet criteria for billing or reimbursement consideration. The medical records provided do not include documentation detailing total time spent providing Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes, therefore, the service cannot be validated.We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the self-care training and therapeutic activities have not been met. Therefore, we decided that the Plan does not have to pay for self-care training (97535) and therapeutic activities (97530) provided on July 2, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the oophorectomy provided on October
21, 2019.
You asked the Plan to waive the coinsurance for the oophorectomy. You say that the surgery was necessary so
you can have your knee replacement surgery. 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 20%
coinsurance for surgery services at an in-network outpatient hospital.
You have been asked to pay $919.17 which is 20% of the allowed amount for the oophorectomy. The allowed
amount is $4,595.85. ($4,595.85 x 20% = $919.17). The oophorectomy falls within the "Outpatient surgery,
including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that
the Plan does not have to waive the coinsurance for the oophorectomy provided on October 21, 2019.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for presbyopia correcting function of intraocular lens (P-C IOL) provided on
November 21, 2019 & December 5, 2019. You asked the Plan to pay for the P-C IOL. You say that it was recommended to improve your vision and you will not have to wear eyeglasses, which will be a savings in the long run for you. The Plan denied your request. The Plan says P-C IOL is excluded from coverage by Medicare and the Plan. The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives a P-C IOL during cataract surgery, the enrollee will be responsible for the difference in cost between the P-C IOL and a conventional IOL. While a P-C IOL may be appropriate for you, neither the Plan nor Medicare covers the presbyopia-correcting feature of a P-C IOL. Therefore, we decided that the Plan does not have to pay for presbyopia correcting function of intraocular lens (P-C IOL) provided on November 21, 2019 & December 5, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for frames (V2020) and lenses (V2101) purchased October 2, 2019.
You asked the Plan to pay for the vision services. You say that you are submitting the receipt with the proper codes hoping the reimbursement can be processed promptly. The Plan denied your request. The Plan says enrollee's must receive their vision services from an in-network provider.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when you go to a participating vision care provider. We looked at the file and the Plan's rules. vision services provided by out of network providers will not be covered. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to pay for frames (V2020) and lenses (V2101) purchased October 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forthe specialist office visit or the endoscopy provided on September 24, 2019.You asked the Plan to waive the copayments forthe specialist office visit and the endoscopy. You say that you should not be responsible for the copayment because the specialist could not get the endoscope through your esophagus while you were sedated.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 thatyou must pay a $40 copayment for each in-network specialist visit for Medicare-covered benefits and a $250 copayment per visit for in-network Medicare-covered surgical, IV therapy and blood transfusion services. You have been asked to pay a $40 copayment for the specialist office visit and a $250 copayment for the endoscopy. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The endoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The medical record shows you received anesthesia before the procedure was discontinued.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 forthe specialist office visit or the endoscopy provided on September 24, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health care services provided by tje Corporation from September 17, 2019 to September 28, 2019.
You asked the Plan to pay for home health care services. You say that you need these services. The Plan denied your request. The Plan says services from providers that do not participate in Medicare are not covered.
The Plan must follow Medicare rules. Medicare rules say that home health services are covered only when the home health agency that is providing the services to the beneficiary has in effect a valid agreement to participate in the Medicare program We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health care services have not been met. The provider you received these services from does not participate in the Medicare program. Therefore, we decided that the Plan does not have to pay for home health care services provided by the Corporation from September 17, 2019 to September 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora bone marrow biopsy provided on May 20, 2019.You asked the Plan to waive the copayment fora bone marrow biopsy. You say that you met the MOOP amount for the year and disagree with 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 $300 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You had a bone marrow biopsy on May 20, 2019. The record shows that you had only paid $3,100 toward the MOOP amount of $3,400 prior to receiving the services. Therefore, you are responsible to pay the $300 copayment. You have been asked to pay a $300 copayment for a bone marrow biopsy. A bone marrow biopsy falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment fora bone marrow biopsy provided on May 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit
You asked the Plan to waive the copayment for a specialist visit. You say that you disagree with the charges because you are unhappy with the service you received. 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 $45 copayment for each specialist visit. You have been asked to pay a $45 copayment for a specialist visit. A specialist 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 a specialist visit provided
We note your complaint that you are unhappy with the service you received. Your complaint is a grievance that must be answered by the health plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eight fractions of brachytherapy treatment for the enrollee.
You asked the Plan to pre-approve the treatment. You say that this is medically necessary. The Plan denied your request. The Plan says the medical necessity could not be established.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are 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 treatment. Our reviewer says that the requested treatment is not considered medically reasonable and necessary in this case. Our physician reviewer found from the "evidence blocks' of the most recent (v1.2020) NCCN guidelines - brachytherapy is only listed for recurrent vulvar cancer. As T3 cancers invade into the bladder, rectum, pelvic bone, or upper part of the urethra or vagina, perhaps one could make an argument for the need of brachytherapy (specifically for vaginal invasion as with this patient, since brachytherapy is used for primary vaginal cancers). However, there is no justification for need of brachytherapy in the consult note or other documents and there is no letter of appeal from the radiation oncologist. As the ASTRO Model Policy requires document of need, and the use of brachytherapy is not standard (per NCCN guidelines), this does not seem to be furnished in accordance with accepted standards 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 the treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve eight fractions of brachytherapy treatment for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the radiation therapy provided on January 14, 2019.
You asked the Plan to waive the coinsurance for the radiation therapy. You say that you were told your treatment would be 100% covered. You say you only went forward with treatment because you were told you had 0% responsibility. 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 20% coinsurance for in-network therapeutic radiology. You have been asked to pay $88.77 which is 20% of the allowed amount for the radiation therapy. The allowed amount is $443.86. ($443.86 x 20% = $88.77). The radiation therapy 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 coinsurance for the radiation therapy provided on January 14, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Magnetic Resonance Imaging (MRI) of the Spine (72146) provided October 16, 2019 
You asked the Plan to waive the copayment for the MRI. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct copayment was applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 copayment for Diagnostic Radiology Services. You have been asked to pay a $200 copayment for the MRI. The MRI falls within the Diagnostic Radiology 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 Magnetic Resonance Imaging (MRI) of the Spine (72146) provided October 16, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for removal of benign odontogenic cysts or tumors (D7450) and alveoloplasty (D7310) provided on September 24, 2019. You asked the Plan to pay for removal of benign odontogenic cysts or tumors and alveoloplasty. You say that this should be considered medical, not dental. The Plan denied your request. The Plan says these services are not Medicare-covered dental services. Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for removal of benign odontogenic cysts or tumors (D7450) and alveoloplasty (D7310) provided on September 24, 2019.