Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided by a physical therapy 
assistant on August 31, 2021. 
 
You asked the Plan to pay for physical therapy services. You say that plans are required to pay non-contract 
providers at the preferred provider rate when services are not available from preferred providers in the service 
area. You say that the in-network benefits should be honored, and the claim processed for payment. 
 The Plan denied your request. The Plan says the code is not appropriate for the service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the services of a physical therapy assistant (PTA) 
shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they 
do not meet the qualifications of a therapist. 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of physical therapy services have not been met. Specifically, the billing provider is a nurse 
practitioner, and not a licensed therapist. As such, PTA services cannot be paid incident to this provider's 
professional services. Therefore, we decided that the Plan does not have to pay for physical therapy services 
provided by a physical therapy assistant on August 31, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the abdominal ultrasound (76705) provided on January 28, 2022.

You asked the Plan to pay for the ultrasound. You say that the enrollee had multiple exams on the date in question. The Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit exists between 93976 and 76705. This PTP edit has a modifier indicator of 1, meaning modifiers associated with NCCI are allowed. However, an appropriate modifier was not billed with this PTP code edit. This service was not billed 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 76705 is a column II code to column I code 93976. 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 the abdominal ultrasound (76705) provided on January 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial lower denture with a flexible base (D5226). 
 
You asked the Plan to pre-approve the dental item. You say that the enrollee had partial dentures in March 
2021. You say that the enrollee lost the dentures which has caused their condition to deteriorate. You also say 
that the enrollee is low income and has limited benefit. The Plan denied your request. The Plan says dentures 
are covered once every 5 plan years. The Plan also says that the frequency limit has been reached. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and dentures are covered once every 5 
plan years, the frequency limit has been reached. The record shows that the Plan paid for a partial lower 
denture that you received on March 2, 2021. Therefore, we decided that the Plan does not have to pre-approve 
a partial lower denture with a flexible base (D5226).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on September 20, 2021. 
 
You asked the Plan to pay for ambulance services. The Plan denied your request. The Plan says an EOB from 
the primary insurance was not provided. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has made 
attempts to obtain the EOB from the primary insurance company. As the secondary insurer, the Plan cannot be 
held responsible for ambulance services until the primary insurer has denied the claim for these services. 
Therefore, we decided that the Plan does not have to pay for ambulance services provided on  
September 20, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited bilateral noninvasive physiologic studies of upper or 
lower extremity arteries provided on September 21, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for limited bilateral noninvasive physiologic studies of upper or lower extremity 
arteries. You say that you are appealing with supporting records. The Plan denied your request. The Plan says 
the services were not authorized because this provider is a non-network provider who does not work with the 
member's health plan, and the member was referred by a provider who also does not work with the Plan. The 
Plan also says that the member's primary care physician did not refer for services. 
 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 limited bilateral noninvasive physiologic studies 
of upper or lower extremity arteries provided on September 21, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an out-of-network provider on 
October 6, 2021, to October 20, 2021. 
 
You asked the Plan to pay for dental services. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says services provided out-of-network are not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers covered 
dental services when provided by a participating provider.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of dental services have not been met. Therefore, we decided that the Plan does not have to pay for 
dental services provided by an out-of-network provider on October 6, 2021, to October 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary or rest home visit for the evaluation and 
management of a new patient (99325) rendered by the out-of-network (OON) provider on October 22, 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 domiciliary or rest home visit for the evaluation and management of a new patient 
(99325) rendered by the out-of-network (OON) provider on October 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established 
patient (D0150) provided January 25, 2022. 
 
You asked the Plan to pay for the comprehensive oral exam. You say that you went to a new dentist because 
you were unhappy with the first dentist you saw. The Plan denied your request. The Plan says you have 
exceeded the frequency limit for this service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the 
comprehensive oral exam once every three plan years.  
 
We looked at the file and Medicare rules. The Plan provided documentation showing that a comprehensive 
exam was previously covered on December 2, 2021. Based on this information, we decided that the Plan's 
frequency limit for coverage of the comprehensive oral exam has been exceeded. Therefore, we decided that 
the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150) 
provided January 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids provided on January 21, 2022. 
 
You asked the Plan to pay for the hearing aids. The Plan denied your request. The Plan says hearing services 
are only covered through the Plan's hearing provider. 
 
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.  
 
We looked at the file and the Plan's rules. The file shows that the hearing aids were not provided by the Plans 
hearing provider. Based on this information, we decided that the Plan's rules for coverage of the hearing aids 
have not been met. Therefore, we decided that the Plan does not have to pay for hearing aids provided on 
January 21, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital outpatient clinic visit for assessment and 
management of a patient provided on November 8, 2021. 
 
You asked the Plan to pay for hospital outpatient clinic visit for assessment and management of a patient. The 
Plan denied your request. The Plan says there were no medical records provided for this date of service. The 
Plan says the Plan is unable to establish medical necessity criteria due to lack of clinical information received. 
 
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 hospital outpatient clinic visit for 
assessment and management of a patient provided on November 8, 2021 have been met. Therefore, we decided 
that the Plan does not have to pay for hospital outpatient clinic visit for assessment and management of a 
patient provided on November 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (0242U) provided on July 7, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided 
that the Plan does not have to pay for the laboratory services (0242U) provided on July 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve addition to lower limb prosthesis, multiaxial ankle with 
swing phase active dorsiflexion feature (CPT code L5968) and all lower extremity prostheses, flex-walk system 
or equal (CPT code L5981). 
 
You asked the Plan to pre-approve the items. You say that the items are needed. The Plan denied your request. 
The Plan says the records do not show why the requested advanced foot and ankle are needed. 
 
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 items. Our physician reviewer 
found the addition to lower limb prosthesis, multiaxial ankle with swing phase active dorsiflexion feature (CPT 
code L5968) and all lower extremity prostheses, flex-walk system or equal (CPT code L5981) are not 
medically necessary as the documentation does not support that you are a K3 ambulator. A November 3, 2021, 
seating and mobility document notes that you would benefit from a power wheelchair to increase function, 
mobility, and promote greater independence. Patient current using manual wheelchair for mobility-related 
activities of daily living (MRADLs), but it is not appropriate and would benefit from a power wheelchair. You 
require mobility assistive device for ADLs and cannot stand for prolonged periods while maintaining sufficient 
balance, and that you are unable to perform home 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 the items have not been met. Therefore, we decided that the Plan does not have 
to pre-approve addition to lower limb prosthesis, multiaxial ankle with swing phase active dorsiflexion feature 
(CPT code L5968) and all lower extremity prostheses, flex-walk system or equal (CPT code L5981).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for paramedic intercept services provided on February 16, 2021. 
 
You asked the Plan to pay for paramedic intercept services. The Plan denied your request. The Plan says er 
Chapter 10 of the Medicare Benefit Policy Manual, paramedic intercept services furnished on or after 
03/01/1999 are payable separate from the ambulance transport when all of the requirements in the following three conditions are met. The intercept service(s) is: 1) furnished in a rural area, 2) furnished 
under a contract with one or more volunteer ambulance services, and 3) medically necessary based on 
the condition of the beneficiary receiving the ambulance service. 
 
The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by 
an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. 
Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as 
defined above. It is noted that the only State in which these criteria are met is New York. 
 
The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural 
according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for paramedic 
intercept services provided on February 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for the complete denture - maxillary 
(D5110) and complete denture - mandibular (D5120) provided November 11, 2021. 
 
You asked the Plan to provide additional payment for the complete upper and lower denture. You say that you 
were unaware that you would owe anything from the procedure. The Plan denied your request. The Plan says 
you have exceeded your annual dental maximum. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the complete 
upper and lower denture up to the $1,000 annual dental maximum.  
 
We looked at the file and Medicare rules. The Plan provided documentation showing that at the time the 
dentures were provided you had $557 remaining in your annual maximum. This amount was applied to your 
upper dentures. You were asked to pay the amount above the dental maximum. Therefore, we decided that the 
Plan does not have to provide additional payment for the complete denture - maxillary (D5110) and complete 
denture - mandibular (D5120) provided November 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you have flat feet, and it is hard to walk because 
of the way your toes are crooked. You cannot stand very long. The Plan denied your request. The Plan says this 
item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377), expandable controller 
harness (E2313), and electronic connection (E2311). 
 
You asked the Plan to pre-approve an expandable controller (E2377), expandable controller harness (E2313), 
and electronic connection (E2311). You say that the requested expandable controller (E2377), expandable 
controller harness (E2313), and electronic connection (E2311) to control power tilt, recline and power 
elevating leg rests through the joystick are medically necessary. The Plan denied your request. The Plan says 
the requested expandable controller (E2377), expandable controller harness (E2313), and electronic connection 
(E2311) to control power tilt, recline and power elevating leg rests through the joystick are not medically 
necessary. 
 
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 an expandable controller (E2377), 
expandable controller harness (E2313), and electronic connection (E2311). Our reviewer says that the 
requested expandable controller (E2377), expandable controller harness (E2313), and electronic connection 
(E2311) to control power tilt, recline and power elevating leg rests through the joystick are not medically 
necessary. Our physician reviewer found the enrollee does not require non-proportional input devices (e.g., sip 
and puff, head array, etc.). The enrollee does not require a separate display (i.e., for alternate control devices), 
other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive 
control), or an attendant control. The enrollee has 3 power options of tilt, recline, and power elevating leg rests 
but the enrollee does not need to control the power options through a joystick. The enrollee's upper extremity 
strength supports that the enrollee can control any power options through their own switches. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an expandable controller (E2377), expandable controller harness (E2313), and 
electronic connection (E2311) have not been met. Therefore, we decided that the Plan does not have to pre-
approve an expandable controller (E2377), expandable controller harness (E2313), and electronic connection 
(E2311).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive exam (D0150) and complete series of x-
rays (D0210) provided on January 11, 2022. 
 
You asked the Plan to pay for the dental exam and x-rays. You say that you believed you selected a provider on 
the Plan's list of network providers. The Plan denied your request. The Plan says the provider in this case is 
out-of-network, and out-of-network services are not covered. The Plan also says that the information you were 
provided on the phone and via email did not list this provider as an in-network provider. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, items or services received from an out-
of-network provider are not covered under this benefit. Therefore, we decided that the Plan does not have to 
pay for the comprehensive exam (D0150) and complete series of x-rays (D0210) provided on January 11, 2022.