Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee does not 
meet the criteria for an IRF admission. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found based on the documentation provided, the health Plans denial should be upheld. The 
enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollees care 
needs can be met at a lower level of care (ex. skilled nursing facility, home health, outpatient therapy). 
 
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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for skilled nursing services provided from 
December 10, 2021, to December 13, 2021. 
 
You asked the Plan to waive the deductible for the skilled nursing services. You say that these services should 
be fully covered with no remaining balance to you. The Plan denied your request. The Plan says the correct 
amount was applied to your deductible. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $203 deductible which applies to certain items and services.  
 
The item or service you asked the Plan to waive the deductible for falls within the Skilled Nursing Facility 
(SNF) Care benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that 
there is $203 deductible which applies to certain items and services. This cost sharing is a contractual 
obligation that had not been met at the time the skilled nursing services were received from December 10, 
2021, to December 13, 2021. Therefore, we decided that the Plan does not have to waive the deductible for 
skilled nursing services provided from December 10, 2021, to December 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Methadone treatment (G2067) rendered by the out-of-
network (OON) provider on August 24, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the Methadone treatment (G2067) rendered by the out-of-network (OON) provider on 
August 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on December 14, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for home health services. You say that it is not the providers' responsibility to obtain 
authorization. The Plan denied your request. The Plan says the services were provided out-of-network and were 
not approved in advance. 
 
 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 had network providers 
available who could have provided 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 home health services provided on December 14, 
2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care visit provided on October 
30, 2021. 
 
You asked the Plan to waive the copayment for the urgent care visit. You say that you did not see a doctor or 
an urgent care center. You say that you only had a COVI-19 test done. 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 urgent care visit.  
 
You have been asked to pay a $40 copayment for the urgent care visit. Please note that the copayment applies 
regardless of the visit reason, including COVID-19 testing. The urgent care visit falls within the Urgently Needed 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 an urgent care visit 
provided on October 30, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy provided on 
January 4, 2022. 
 
You asked the Plan to waive the copayment for a diagnostic colonoscopy. You say that it is medically 
necessary for you to have a colonoscopy yearly due to your medical conditions. You also say it should be 
covered under routine because these are routine services 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 $200 
copayment for in-network outpatient surgery.  
 
 The medical records show you had a diagnostic colonoscopy on January 4,2022, which has a cost sharing 
amount. You have been asked to pay a $200 copayment for a diagnostic colonoscopy. A diagnostic 
colonoscopy 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 for a 
diagnostic colonoscopy provided on January 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on 
November 12, 2021. 
 
You asked the Plan to waive the copayment for the specialist visit. You say that the visit was a result of injury 
while hospitalized with COVID-19. 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 $35 
copayment for specialist services.  
 
You have been asked to pay a $35 copayment for the specialist visit. Please note that there are no cost share 
waivers in effect for COVID-19 treatment or injury. The 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 office visit provided on November 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the LipiFlow Thermal Pulsation (codes 0207T and 99199) 
you received on October 15, 2021. 
 
You asked the Plan to pay for the LipiFlow Thermal Pulsation. You say that your condition causes eye dryness, 
dripping and inflammation and this service was needed to normalize your vision and eye function. The Plan 
denied your request. The Plan says this is not a covered service. 
 
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 LipiFlow Thermal Pulsation. Our 
reviewer says that the LipiFlow Thermal Pulsation services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found there is no single accepted gold standard treatment for 
meibomian gland dysfunction. The documentation in the case file does not demonstrate that the procedure met but did not exceed, your medical need, and was at least as beneficial as an existing and available medically 
appropriate alternative. 
 
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 LipiFlow Thermal Pulsation have not been met. Therefore, we decided that 
the Plan does not have to pay for the LipiFlow Thermal Pulsation (codes 0207T and 99199) you received on 
October 15, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 92546, 92700, and 92538 billed for date of service 
September 16, 2021. 
 
You asked the Plan to pay for codes 92546, 92700, and 92538. You say that the records support separate 
payment for these codes. The Plan denied your request. The Plan says that all of these codes are bundled into 
payment for code 82540 because these codes are integral to 92540. 
 
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, we have confirmed that code 92546, 
92700, and 92538 is a column II code to column I code 92546, 92700, and 92538; however, 92546, 92700, and 
92538 was billed with a modifier. 
 
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 codes 92546, 92700, and 92538. Our reviewer says that 
separate payment of codes 92546, 92700, and 92538 is supported in the medical record. Our reviewer found for 
code 92546, basic vestibular evaluation does not include a sinusoidal rotational test, and therefore should be 
covered separately. For code 92700, there is currently no specific CPT code for vestibular evoked myogenic 
potential (VEMP) or video head impulse testing (vHIT).  Since there is not a code available, code 92700 
(unlisted) otorhinolaryngological service or procedure) is recommended. In this case, this procedure was 
performed and should be covered. For code 92538, caloric irrigations are not included as part of the basic 
vestibular evaluation and should be billed separately. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes 92546, 92700, and 92538 have been met. Therefore, we decided that the 
Plan has to pay for procedure codes 92546, 92700, and 92538 billed for date of service September 16, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for podiatry specialist office visits provided 
from June 29, 2021, to July 12, 2021. 
 
You asked the Plan to waive the copayments for specialist office visits. You say that you paid one of your 
copayments and the claim for July 12, 2021, is for an appointment you did not have. 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 $30 
copayment for a specialist office visit.  
 
The medical records show you had a podiatry specialist office visit on June 29, 2021, July 7, 2021, and July 
21,2021. You have been asked to pay a $30 copayment for each specialist office visit. A specialist office visit falls within the Physician/Practitioner Services, Including Doctors 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 copayments for podiatry specialist office visits provided from June 29, 2021, to July 
12, 2021.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Yescarta. 
 
You asked the Plan to pre-approve Yescarta. You say that without this drug the patient is at risk of disease 
progression and is not able to proceed with other treatment. The Plan denied your request. The Plan says that 
the patient does not meet medical necessity criteria for this drug. 
 
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 this 
drug is medically appropriate for the patient. Our physician reviewer found this patient has received greater 
than 2 lines of prior therapy. The medical documentation supports that this drug is safe and effective for the 
patient. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
Yescarta.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that you need SNF care because you were in the 
hospital in April and you need to go to rehab.  You said you are not safe to be home and you have no 
assistance. The Plan denied your request. The Plan says that SNF services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has provided zero medical records with this case file.  
Even when we requested medical records, the Plan failed to provide them, despite the fact that the providers 
from whom these records are needed are contract providers. It isn't clear how the Plan made its determination 
that SNF care is not medically necessary for you if they had no records to review. Therefore, we decided that 
the Plan has to pre-approve skilled nursing facility (SNF) services.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Methadone treatment (G2067) rendered by the out-of-
network (OON) provider on November 8, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the Methadone treatment (G2067) rendered by the out-of-network (OON) provider on 
November 8, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an ultrasound of the abdomen provided on 
December 21, 2021. 
 
You asked the Plan to reduce the copayment for the ultrasound. You say that you were not informed of your 
liability before the test. 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 $125 
copayment for radiological diagnostic services performed in a free-standing clinic, such as ultrasounds.  
 
You have been asked to pay $107.43, which is less than the $125 copayment for the ultrasound. The ultrasound 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 reduce the copayment for an ultrasound of the abdomen provided on December 21, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a primary care physician (PCP) office visit 
provided on December 9, 2021. 
 
You asked the Plan to waive the copayment for the PCP visit. You say that you thought this was all part of your 
annual visit. 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 $0 copayment for routine physical exams. A separate cost sharing may apply if additional services are provided. 
 
Your contract with the Plan also clearly says that you must pay a $15 copayment for each primary care 
provider visit. 
 
The file shows that you had additional services provided at your annual visit, including a referral for nasal 
issues. These services go beyond the scope of an annual visit. Therefore, you have been asked to pay a $15 
copayment for the PCP visit. The PCP 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 primary care physician 
(PCP) office visit provided on December 9, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the mental health visit provided on 
November 17, 2021. 
 
You asked the Plan to waive the copayment for the mental health visit. You say that you had a telehealth visit 
which is a $0 copay so you should not be charged. The Plan denied your request. The Plan says the copayment 
applied correctly.  
 
Per page 88 of the Plan's 2021 (EOC), telehealth visits are only covered for monthly end-stage renal disease-
related visits for home dialysis members in a hospital-based or critical access hospital-based renal dialysis 
center, renal dialysis facility, or the members home. Telehealth services for diagnosis, evaluation, or treatment 
of symptoms of an acute stroke are also covered.  
 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 per individual or group visit for outpatient mental health visits.  
 
You have been asked to pay $40 your mental health visit. Outpatient mental health visits fall within the 
Outpatient mental health care benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
the outpatient mental health visit provided on November 17, 2021.