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

 
We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy with lesion 
removal provided on January 27, 2022. 
 You asked the Plan to waive the copayment for a diagnostic colonoscopy. You say that this was a surveillance 
colonoscopy. 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 $300 
copayment for in-network surgical services, including a diagnostic colonoscopy at an ambulatory surgical 
center. The Plan contract also says that there is a $0 copayment for in-network colorectal cancer screening 
exam. The contract says separate cost sharing may apply if additional services are provided. See the Outpatient 
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers for cost 
sharing information when colonoscopy services are considered diagnostic rather than screening (for example, 
personal history or current symptoms). 
 
The medical record shows the reason for the colonoscopy was for personal history of polyps. According to the 
EOC, colonoscopy services are considered diagnostic rather than screening when performed due to having a 
personal history. You have been asked to pay a $300 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 with lesion removal provided on January 27, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient rehabilitation care provided from 
November 1, 2021, to November 9, 2021. 
 
You asked the Plan to waive the copayment for the inpatient rehabilitation care. You say that this should be 
considered one single stay without a separate copayment. 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 $200 per 
day for days 1-8 and $0 per day for additional days for each inpatient or inpatient rehabilitation admission.  
 
The file shows that you were discharged from inpatient status on November 1, 2021, and admitted to the rehabilitation center from November 1, 2021, to November 9, 2021. This transfer to a separate department is 
considered a new admission. Therefore, you have been asked to pay $200 per day for the first 8 days of 
inpatient rehabilitation care. The total for your stay is $1,600 ($200 copayment x 8 days = $1,600). The 
inpatient rehabilitation care falls within the Inpatient Hospital 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 inpatient rehabilitation care provided from November 1, 2021, to November 9, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician's services provided on February 18, 2022. 
 
You asked the Plan to pay for the physician's services. You say that you were told by the representative who set 
up the appointment that they are participating with the Plan. The Plan denied your request. The Plan says you 
must receive your care from a network provider. The only exceptions are emergencies, urgently needed 
services when the network is not available, and cases in which the Plan authorizes use of out-of-network 
providers. 
 
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 the physician's services provided on February 18, 2022.
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 an admission is medically necessary. The Plan 
denied your request. The Plan says an admission is not medically necessary. 
 
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 at the current functional level, the enrollee needs skilled nursing facility rehab, and does not require 3 hours a day five days a week of IRF therapies with interdisciplinary management. 
 
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 waive the copayment for a vision exam on March 9, 2022. 
 
You asked the Plan to waive the copayment for a vision exam. You say that it was a routine eye exam and you 
should not be responsible for the $45 copay. The Plan denied your request. The Plan says the member is 
responsible for a copayment for each office visit to a specialist. 
 
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 a vision exam.  
 
You have been asked to pay a $45 copayment for the vision exam. Although you stated that this was a routine 
vision exam for which no copayment should apply, the medical records from this visit show that this was a 
medical office visit.  Specifically, the doctor evaluated you for both an age-related nuclear cataract and 
squamous blepharitis of the left lower eyelid.  The fact that you did not receive treatment for the cataract and a 
later vision exam indicated that you did not have the blepharitis condition does not change the billing of the 
visit in question from being a medical visit to a routine one. 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 vision exam on March 9, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for short-latency somatosensory evoked potential study, 
stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper limbs 
(CPT code 95925) and central motor evoked potential study (transcranial motor stimulation); upper limbs (CPT 
code 95928) provided on October 14, 2021. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. The file shows that the diagnosis 
code on the claim is M19.012: Primary osteoarthritis, left shoulder. The rules say that there are specific ICD-10 
codes to support medical necessity and provide coverage for CPT codes 95925, 95926, 95927, 95928, 95929, 
95938, and 95939). Therefore, the diagnosis code listed on the claim is not one of the ICD-10 codes to support 
medical necessity. Therefore, we decided that the Plan does not have to pay for short-latency somatosensory 
evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper limbs (CPT code 95925) and central motor evoked potential study (transcranial motor 
stimulation); upper limbs (CPT code 95928) provided on October 14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Inpatient stay from November 27, 2021 to 
November 29, 2021. 
 
You asked the Plan to waive the copayment for Inpatient stay. You say that you would like to appeal the cost 
share. The Plan denied your request. The Plan says the cost share applied is correct. 
 
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 $175 
copayment per day for Inpatient stay. The $175 copayment per day is applied twice, therefor the total 
copayment due is $350. 
 
You have been asked to pay a $175 copayment per day for Inpatient stay. Inpatient stay falls within the 
Inpatient hospital 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 Inpatient 
stay from November 27, 2021 to November 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the placement of a second iStent (0376T) provided on 
November 3, 2021. 
 
You asked the Plan to pay for the placement of a second iStent. You say that this is payable because more than 
one iStent was implanted. The Plan denied your request. The Plan says this cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare considers one iStent, iStent inject, or 
Hydrus device per eye medically reasonable and necessary. 
 
We looked at the file and Medicare rules. Medicare considers only one iStent device per eye medically 
reasonable and necessary. Based on this information, we decided that Medicare rules for coverage of the 
placement of a second iStent have not been met. Therefore, we decided that the Plan does not have to pay for 
the placement of a second iStent (0376T) provided on November 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for positional nystagmus test (CPT code 92532) provided on 
January 4, 2022. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is not covered as 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. 
 
CPT code 92532 has a status indicator of 'B' on the CMS Physician Relative Value File, is always bundled into payment for other services not specified and no separate payment is made per Medicare. Therefore, we decided 
that the Plan does not have to pay for positional nystagmus test (CPT code 92532) provided on January 4, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 24, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 an office visit provided on February 24, 2022 by 
an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient psychiatric services provided on October 2, 2021, 
to October 9, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for inpatient psychiatric services. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says an authorization is required for inpatient hospital care, 
and as of today there is no approved authorization for the rendered dates of service. 
 
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 inpatient psychiatric services provided on October 
2, 2021, to October 9, 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 the specialist telehealth visit provided by a 
network provider on March 10, 2022. 
 
You asked the Plan to waive the copayment for the specialist telehealth visit. You say that you do not feel like 
you should have to pay the same copayment because you were seen by the physician's assistant and not the 
doctor. The Plan denied your request. The Plan says you have been asked to pay 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 each in-network specialist telehealth visit.  
 You have been asked to pay a $35 copayment for the specialist telehealth visit. The specialist telehealth visit 
falls within the Physician/Practitioner services, including doctors office visits benefit category. The record 
shows the physicians assistant is considered a practitioner. 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 specialist telehealth visit provided by a network provider on March 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for hearing aids provided on June 17, 2021. 
 
You asked the Plan to reimburse you for hearing aids. The Plan denied your request. The Plan says prior 
authorization is required for all out-of-network providers. Prior authorization was not found in the Plan's 
system. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when received from a participating provider. 
 
We looked at the file and the Plan's rules. The file shows that the hearing aids were not received from a 
participating provider. Based on this information, we decided that the Plan's rules for coverage of hearing aids 
have not been met. Therefore, we decided that the Plan does not have to reimburse you for hearing aids 
provided on June 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan of the 
lumbar spine provided on October 21, 2021. 
 
You asked the Plan to waive the copayment for a CT scan. You say that when you arrived to have the CT scan 
it had to be rescheduled at a different facility due to a stimulator implant. 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 $150 
copayment for advanced imaging services, including CT scans.  
 
The medical record shows the enrollee had a CT scan on October 21, 2021. The enrollee has been asked to pay 
the allowed amount of $95.94, which is less than the $150 copayment for a CT scan.  A 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 a computed tomography (CT) scan of the lumbar spine 
provided on October 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on January 26, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the enrollee has been seeing this doctor since 2017. 
The Plan denied your request. The Plan says no prior authorization was obtained. 
 
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 office visit in this appeal. The Plan did not pre-approve the office visit. 
The records provided for review do not show that the office visit was urgent or emergent. 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 office visit provided on January 26, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the oxygen concentrator provided by a 
network provider on January 3, 2022. 
 
You asked the Plan to waive the deductible for the oxygen concentrator. You say that you have never received 
a bill this high for your oxygen equipment. The Plan denied your request. The Plan says you have been asked 
to pay the correct cost-sharing amount. 
 
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 a $250 deductible which applies the oxygen concentrator. 
 
The oxygen concentrator you asked the Plan to waive the deductible for falls within the Durable Medical 
Equipment (EOC) and Related Supplies benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $250 deductible which applies to the oxygen concentrator.  This cost sharing is a contractual obligation that had not been met at the time the oxygen concentrator was 
received on January 3, 2022. Therefore, we decided that the Plan does not have to waive the deductible for the 
oxygen concentrator provided by a network provider on January 3, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc-one. 
 
You asked the Plan to pre-approve Synvisc-one. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says it was confirmed with the provider's office that Synvisc-
one will be supplied by a pharmacy. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Synvisc-one.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 24, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that this provider is new to your practice since July 1, 
2021, and should be in process with credentialing if not already done with this Plan. You also say that in the 
meantime you would like to appeal for continuity of care, as this is not a new patient to this provider. The Plan 
denied your request. The Plan says the request is for services by a non-contracted provider for dates of service 
September 24, 2021. The Plan also says there is no referral letter from an in-network physician, and the 
services were not medically necessary. 
 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 an office visit provided on September 24, 2021, by 
an out-of-network (OON) provider.