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

 
We decided that the Plan does not have to pay for the bunionectomy provided on February 19, 2020. 
 
You asked the Plan to pay for the bunionectomy. The Plan denied your request. The Plan says this is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the bunionectomy provided on 
February 19, 2020. have been met. The submitted documentation does not contain medical records from the non-contract provider. Therefore, we decided that the Plan does not have to pay for the bunionectomy provided 
on February 19, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from February 7, 
2022, through February 8, 2022. 
 
You asked the Plan to pay for the acute inpatient hospital care. You say that the inpatient hospital care provided 
was medically necessary. The Plan denied your request. The Plan says the services were rendered by an out-of-
network provider, without prior authorization. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the acute inpatient hospital care.   
Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found that you presented to the hospital on February 7, 2022 with symptoms of 
shortness of breath and a painful right great toe. You underwent lab testing, a chest x-ray, and an evaluation by 
a podiatrist. Your vital signs were stable and you did not require any oxygen. The Podiatrist determined that 
you had an ingrown toenail and removed it; you were then discharged on February 8, 2022. The review has 
determined that the record did not show that at the time of inpatient admission the admitting physician 
reasonably expected that your necessary hospital care (including earlier emergency department (ED) and/or 
observation care) would span two midnights. 
 
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 acute inpatient hospital care have not been met. Therefore, we decided that 
the Plan does not have to pay for the acute inpatient hospital care provided from February 7, 2022, through 
February 8, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan services billed with 
code 71250 provided on November 23, 2021. 
 
You asked the Plan to pay for the CT scan services as billed. You say that you would like this claim 
reprocessed based on the medical records. The Plan denied your request. The Plan says the provider did not bill 
as required by Medicare coding regulations. 
 
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 71250 
is a column II code to column I code 71260 with a modifier indicator of 0. The column II code is therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for the computed tomography (CT) scan services billed with code 71250 
provided on November 23, 2021.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to waive the refund request for the outpatient rehabilitation services provided on 
February 1, 2021. 
 
You asked the Plan to waive the refund request for the outpatient rehabilitation services. You say that the 
enrollee's plan says they paid the claim twice. You also say that the accounting department verified that this 
amount was not received for the enrollee. The Plan denied your request. The Plan says that overpayment was 
made initially. The Plan also says that the overpayment amount should be paid from the provider. 
 
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 did not substantiate that 2 payments were made. Therefore, 
we decided that the Plan has to waive the refund request for the outpatient rehabilitation services provided on 
February 1, 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 pay for the shingles vaccine provided March 3, 2022 
 
You asked the Plan to pay for the shingles vaccine. You say that you should have been told before you got the 
shot that there would be a charge. You are on social security and cannot afford paying for a shot that you never 
would have agreed to had you known there was a charge. The Plan denied your request. The Plan says this 
service is not covered under the Plan benefits. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the shingles 
vaccine. Therefore, we decided that the Plan does not have to pay for the shingles vaccine provided March 3, 
2022  
 
Benefits for the shingles vaccine may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs a program that provides advanced 
therapy techniques. The Plan denied your request. The Plan says that the stay is not medically necessary based 
on IRF criteria. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found clinical documentation states that enrollee has multiple active two or more diseases or medical 
conditions which would benefit from close medical supervision. The evaluating therapists state that the enrollee 
would benefit from intense therapy and would be able to tolerate and benefit from multi-disciplinary 
rehabilitation. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute IRF admission and 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $250 copayment for ambulance transportation provided on 
February 15, 2021. 
 
You asked the Plan to waive the $250 copayment for ambulance transportation provided on February 15, 2021. 
You say that you have already paid this, and this copayment should be waived. The Plan denied your request. 
The Plan says you are responsible to pay a $250 copayment per one-way trip by ground ambulance. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for Ambulance Services.  
 
You have been asked to pay a $250 copayment for ambulance transportation. Ambulance transportation falls 
within the Ambulance 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 $250 copayment 
for ambulance transportation provided on February 15, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76937 billed for date of service February 8, 
2022. 
 
You asked the Plan to pay for procedure code 76937. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says payment for code 76937 is bundled into 
payment for code 93970. 
 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 76937 
is a column II code to column I code 93970. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76937 billed for date of service February 8, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visit provided on 
November 15, 2021. 
 
You asked the Plan to waive the copayment for specialist office visit. You say that this was a follow up visit for 
your heart surgery so it should be covered. The Plan denied your request. The Plan says the copayment 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 $40 
copayment per visit to a specialist.  
 
You have been asked to pay $40 copayment for specialist office visit. Specialist office visits fall 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 copayment for specialist office visit provided on November 15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
February 8, 2022, to February 10, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the enrollee had an abnormal 
electrocardiogram and an elevated blood pressure. The Plan denied your request. The Plan says there was eye 
pain, but no other acute symptoms. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the enrollee presented to the emergency department with elevated blood pressure, and 
right eye pain, gradually worsening over the past 2-3 days. She reported chest pain the night before that has 
since resolved. The right eye was red and she expressed photophobia (chronic). No fever, chills, headache, 
dizziness, vision changes, drainage, pain with range of motion of the eye, palpitations, leg swelling, shortness 
of breath, abdominal pain, nausea/vomiting, or weakness was reported. She was in mild distress but was not 
toxic or ill-appearing. Right conjunctiva was injected but pupils were equal, round, and reactive to light. No 
proptosis or periorbital swelling/erythema was noted. Vitals were normal, cardiac workup was negative. Due to 
the stability of the patient, low complexity, and negative cardiac workup, there was no suggestion this patient 
would require hospital services that would likely cross 2 midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for inpatient hospital services provided to the enrollee from February 8, 2022, to 
February 10, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (37799) provided on November 22, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this code 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 37799 is "Unlisted procedure, vascular surgery". 
 
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 services. Our reviewer says that the use of code 37799 is 
not supported by the records provided. Our reviewer found that the provider failed to put an accurate code 
description in using the unlisted code 37799, with comparison code 35666. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (37799) provided on November 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an upright walker, a Life Glider walker (E1399). 
 
You asked the Plan to pre-approve a Life Glider walker. You say that you are requesting reconsideration for the 
denial of this item and submitting additional information to validate the need. The Plan denied your request. 
The Plan says there is no documentation that a standard rollator walker or walker with a trunk support system 
will not meet your mobility needs. The requested upright walker is considered a convenience item and not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
 
 
 
 
 The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve an upright walker, a Life Glider walker (E1399).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an airway clearing vest (E0483) to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an airway clearing vest. You say that the requested item is medically 
necessary. The Plan denied your request. The Plan says you must receive items/services from an in-network 
provider. There are providers available in your network to provide this care. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
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. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an airway clearing vest (E0483) to be provided by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for ambulance transportation from March 12, 
2022, to April 1, 2022. 
 
You asked the Plan to waive the copayments for ambulance transportation from March 12, 2022, to April 1, 
2022. You say that you cannot afford to pay these copayments. The Plan denied your request. The Plan says 
enrollees must pay a $150 copayment for ambulance transportation. 
 
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 Ambulance Services.  
 
You have been asked to pay a $1500 copayment for ambulance transportation from March 12, 2022, to April 1, 
2022. Ambulance transportation falls within the Ambulance Services benefit category. There were 10 
ambulance transports provided: $150x10=$1500. 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 
ambulance transportation from March 12, 2022, to April 1, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay provided from 
August 21, 2021, to September 4, 2021. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you are being billed more 
then you should due to being transferred to another hospital. The Plan denied your request. The Plan says the 
copayment 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 $275 
copayment per day for days 1 through 5.  
 
You have been asked to pay $1,334.02 ($275 x 5 days) copayment for the inpatient hospital stay. Your 
copayment is $1,334.02 instead of $1,375 because you had reached your out-of-pocket maximum during your 
stay. Inpatient hospital 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 hospital stay provided from August 21, 2021, to September 4, 2021.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve bioimpedance spectroscopy assessment using the ImpediMed L-
Dex testing device. 
 
You asked the Plan to pre-approve bioimpedance spectroscopy assessment using the ImpediMed L-Dex testing 
device. You say that the requested bioimpedance spectroscopy assessment using the ImpediMed L-Dex testing 
device is medically necessary. The Plan denied your request. The Plan says that the requested bioimpedance 
spectroscopy assessment using the ImpediMed L-Dex testing device is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 bioimpedance spectroscopy assessment 
using the ImpediMed L-Dex testing device. Our reviewer says that the requested bioimpedance spectroscopy 
assessment using the ImpediMed L-Dex testing device is medically necessary. Our physician reviewer found 
bioimpedance spectroscopy for breast cancer related lymphedema assessment has become a standard of care for 
prevention and treatment. Use is supported by the National Comprehensive Cancer Network (NCCN) 
Guidelines. Clinical measurements are obtained initially to establish a baseline before breast cancer treatments 
and afterward at intervals to track changes during treatment. Alternatively, changes in arm circumference or 
volume relative to the contralateral normal limb can be performed. Given that the highest risk of developing 
lymphedema is within the first three years of treatment and that early intervention can limit progression of 
disease, high-risk patients should be followed closely in this period. This enrollee who had surgery, lymph 
node sampling, and whole breast radiation would be considered high risk. The service is reasonable and 
medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bioimpedance spectroscopy assessment using the ImpediMed L-Dex testing 
device have been met. Therefore, we decided that the Plan has to pre-approve bioimpedance spectroscopy 
assessment using the ImpediMed L-Dex testing device.  
 
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.