Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) for tooth # 7, core build up (D2950) 
for teeth # 7, 8 and 9, diagnostic casts (D0470), labial veneer (D2962), and the unlisted restorative services 
(D2999 x 3). 
 
You asked the Plan to pre-approve the dental services. You say that you cannot use these crowns to eat. You 
say that they are painful. You say that the crowns are too long and too wide for your healthy teeth. You also 
say that the crowns are affecting my speech and looks. The Plan denied your request. The Plan says crowns and 
core build up are covered once per tooth every 5 plan years. The Plan says that the frequency limit for these 
services have been exceeded. The Plan also says that diagnostic casts, labial veneers, and the unspecified 
restorative service are not listed as covered. 
 
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, The record shows that the Plan paid for 
crowns that you received or teeth # 7, 8 and 9 on January 30, 2020 and core build up that you received for teeth 
# 7, 8 and 9 on January 9, 2020. Additionally, diagnostic casts, labial veneers, and the unspecified restorative 
service are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pre-approve a crown (D2740) for tooth # 7, core build up (D2950) for teeth # 7, 8 and 9, diagnostic casts 
(D0470), labial veneer (D2962), and the unlisted restorative services (D2999 x 3).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa (J7323). 
 
You asked the Plan to pre-approve Euflexxa. You say that the service is medically necessary. The Plan denied 
your request. The Plan says the enrollee has not met the criteria for this service. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Euflexxa. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found that although prior clinical examination and 
diagnostic imaging confirms the presence of osteoarthritis in both knees, and the successful use of 
viscosupplementation, a review of the available medical records reveals a lack of supporting documentation in 
terms of meeting all criteria, specifically, the response to cortisone injections. The documentation does not 
support that Euflexxa is medically necessary or safe and effective for this 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 Euflexxa have not been met. Specifically, the medical records did not show that 
the enrollee met the criteria for this service. This means the service is not medically necessary or reasonable. 
Therefore, we decided that the Plan does not have to pre-approve Euflexxa (J7323).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Superion interspinous spacer for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that this procedure is a safer alternative to a 
laminectomy or spinal fusion procedure. The Plan denied your request. The Plan says that current medical 
literature indicates that this service is considered experimental and investigational. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The device is 
experimental. More research is needed to show safety and efficacy. Our physician reviewer found that the 
enrollee's condition does not meet Medicare criteria for these services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Superion interspinous spacer for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient mental health care provided from September 11, 
2020, to September 15, 2020. 
 
You asked the Plan to pay for the inpatient mental health care. You say that these services were medically 
necessary. The Plan denied your request. The Plan says rules for inpatient mental health care were not met. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient mental health care. Our 
reviewer says that the service was not medically necessary. Our physician reviewer found you did not require 
inpatient mental health treatment beyond the dates in question as you were not a danger to yourself or others 
and did not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was 
taking place beyond the date in question. It did not appear that the services for the dates in question were 
reasonably expected or medically necessary to improve your condition or for the purpose of diagnosis. Your 
care could have been treated in a lesser restrictive setting as you were not showing any suicidal or homicidal 
ideation, auditory or visual hallucinations, delusions and were not showing any behaviors or aggression being 
cooperative and compliant while not showing any acute threats to safety. 
 
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 inpatient mental health care have not been met. Therefore, we decided that 
the Plan does not have to pay for the inpatient mental health care provided from September 11, 2020, to 
September 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diagnostic casts (D0470), extraction, erupted tooth 
(D7210), alveoloplasty in conjunction with extractions (D7310), immediate denture - maxillary  (D5130), and 
unspecified removable prosthodontic procedure (D5899) provided on September 9, 2020, to September 15, 
2020, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the diagnostic casts, extraction, erupted tooth, alveoloplasty in conjunction with 
extractions, immediate denture - maxillary and unspecified removable prosthodontic procedure. You say that 
you thought the provider you saw was in-network. The Plan denied your request. The Plan says for the services 
payable under the dental benefit, the Plan has fully paid, and the remaining amount is your responsibility. For 
the other services not being paid, these services are not covered under your supplemental benefit. 
 
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, the diagnostic casts and the 
unspecified removable prosthodontic procedure are not among those covered under this benefit. Furthermore, 
the Plan has paid for the extraction, erupted tooth, alveoloplasty in conjunction with extractions, and immediate 
denture ? maxillary at the Maximum Allowable Charge. For services with an OON provider, you may be 
subject to the remaining difference between what the provider is billing and the Maximum Allowable Charge.   
 
 
 
 
 
 
 
 
 
Therefore, we decided that the Plan does not have to pay for the diagnostic casts (D0470), extraction, erupted 
tooth (D7210), alveoloplasty in conjunction with extractions (D7310), immediate denture - maxillary  (D5130), 
and unspecified removable prosthodontic procedure (D5899) provided on September 9, 2020, to September 15, 
2020, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a Group 2 power wheelchair and accessories. 
 
You asked the Plan to provide a Group 2 power wheelchair (K0835) and accessories. You say that the enrollee 
needs a Group 2 power wheelchair and accessories. The Plan denied your request. The Plan says the Group 2 
power wheelchair and accessories do not meet the requirements for approval. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file shows that does not contain a Specialty Evaluation or support the criteria for the tilt system. This 
means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does 
not have to provide a Group 2 power wheelchair and accessories.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has spinal stenosis. There 
is no spinal instability. The requested spacer is considered experimental, as more research is needed to show 
safety and efficacy. The services are therefore not 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Vertiflex Superion spacer.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says high 
quality studies are lacking to show this procedure is effective. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician 
reviewer found that you are status post bilateral knee arthroplasties. You have ongoing pain. You have tried 
non-steroidal anti-inflammatory drugs (NSAIDS) and a trial of physical therapy. You had a diagnostic right 
knee genicular nerves block, which produced significant pain relief. The requested service is an 
experimental/investigational procedure that is the subject of on-going clinical trials. Therefore, the request is 
considered not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve genicular nerve radiofrequency ablation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids purchased on June 25, 2020. 
 
You asked the Plan to pay for these services. You say that you would like reimbursement. The Plan denied 
your request. The Plan says the services are not covered. 
 
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 plan's coverage rules apply in this case. The Plan covers one 
hearing aid per ear, per year from a plan-approved provider only.  
 
We looked at the file and the Plan's rules. The file shows that you did not purchase hearing aids from the plan-
approved provider. Based on this information, we decided that the Plan's rules for coverage of these services 
have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids purchased on 
June 25, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to reduce the $40 copayments charged per visit for therapy services 
provided from July 29, 2020 to August 27, 2020 to $10 per visit. 
 
You asked the Plan to reduce these copayments. You say that you were told the visits would be $10. The Plan 
denied your request. The Plan says the contract is clear that therapy visits provided in an outpatient hospital 
setting have a copayment of $40. 
 
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 for each therapy service provided in an outpatient hospital setting.  
 
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 $40 copayments charged per visit for therapy services provided from July 29, 2020 
to August 27, 2020 to $10 per visit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider for an oral 
device/appliance. 
 
You asked the Plan to pre-approve the referral. You say that there is no in-network provider available for this 
device. The Plan denied your request. The Plan says there are network providers available. 
 
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 
a referral to an out-of-network provider for an oral device/appliance.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implant supported porcelain/ceramic crown for tooth 
#30. 
 
You asked the Plan to pre-approve the implant supported crown. You say that your policy book states that 
implants and bone grafting are covered benefits. You also say that your policy book does not state that this 
service is only covered for specific teeth. The Plan denied your request. The Plan says your dental plan limits 
coverage to anterior (front) teeth only for implant services. The Plan also says that tooth #30 is a posterior 
(back) tooth, and it does not qualify for benefits. 
 
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, the requested items or services are not 
covered for posterior (back) teeth. Therefore, we decided that the Plan does not have to pre-approve an implant 
supported porcelain/ceramic crown for tooth #30.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a back brace. 
 
You asked the Plan to pre-approve a back brace. The Plan denied your request. The Plan says the request does 
not meet medical criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that spinal orthoses are only covered under certain 
medical indications. 
 
We looked at the file and Medicare rules. The provided records do not show that the enrollee requires the brace 
to reduce pain by restricting mobility, to facilitate healing following injury or surgery, or to support weak 
spinal muscles. Based on this information, we decided that Medicare rules for coverage of a back brace have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a back brace.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two core buildups, including any pins when required 
(D2950 x2). 
 
You asked the Plan to pre-approve the core buildups. You say that the enrollee needs the buildups to reinforce 
the tooth structure for these teeth. The Plan denied your request. The Plan says this service is not covered. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve two 
core buildups, including any pins when required (D2950 x2).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the durable medical equipment (DME) 
services rendered on July 10, 2020. 
 
You asked the Plan to waive the deductible for these services. You say that you disagree with the charges. The 
Plan denied your request. The Plan says the deductible was applied correctly. 
 
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 $500 yearly deductible for your covered medical services.  
 
The item or service you asked the Plan to waive the deductible for falls within the durable medical equipment 
benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $500 
yearly deductible for your covered medical services. This cost sharing is a contractual obligation that had not 
been met at the time these services were received on July 10, 2020. Therefore, we decided that the Plan does 
not have to waive the deductible for the durable medical equipment (DME) services rendered on July 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodontal maintenance (D4910) provided on January 22, 
2020. 
 
You asked the Plan to pay for a periodontal maintenance. You say that the service should be covered. The Plan 
denied your request. The Plan says this service is not a covered benefit. 
 
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, the requested items or services are not 
among those covered under this benefit. Specifically, the services is not listed in the EOC. This means the 
service is not a covered benefit. Therefore, we decided that the Plan does not have to pay for a periodontal 
maintenance (D4910) provided on January 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chronically ill supplement benefits. 
 
You asked the Plan to pre-approve chronically ill supplement benefits. You say that the services are medically 
necessary. The Plan denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that you may receive supplemental benefits for the 
chronically ill when you have a condition listed on pages 69-70 of the Plan's 2020 EOC. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the supplemental benefits for the chronically ill have not been met. Specifically, there are no 
medical records submitted to show that you have a chronic condition listed in the Plan's EOC that would 
qualify you for this supplemental benefit. Therefore, we decided that the Plan does not have to pre-approve 
chronically ill supplement benefits.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the medical services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve foot surgery. You say that you were told that this was the only facility that 
can perform this procedure. The Plan denied your request. The Plan says the denial of authorization for this 
service is correct, because this provider is out-of-network with the Plan and you can be treated by an in-
network provider. 
 
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 
the medical services to be provided by an out of network (OON) provider.