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

We decided that the Plan does not have to pay the in network rate for the surgical extractions (D7140 x5), the extractions (D7210 x 13), the alveoloplasty in conjunction with an extraction (D7310 x 2), the removal of the torus mandibularis (D7473 x 2), and the unlisted removable prosthodontic service (D5899 x 2) provided on May 18, 2020 by the out of network provider. You asked the Plan to pay the in network rate for the dental services. You say that you were unable to find an in network provider due to the pandemic. The Plan denied your request. The Plan says 6 extractions per calendar year are covered. The Plan says that the frequency limit has been exceeded. The Plan says alveoloplasty in conjunction with an extraction is not listed as a covered service. The Plan says removal of torus mandibularis is not listed as a covered service. The Plan also says the unlisted removable prosthodontic service is not listed as a covered 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. Though the Plan offers a dental benefit in excess of Medicare coverage and extractions are a covered service, the frequency limit has been exceeded. The record shows that the Plan paid for 6 extractions provided on this date of service. Additionally, the alveoloplasty in conjunction with an extraction, removal of torus mandibularis, and the unlisted removable prosthodontic service are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay the in network rate for the surgical extractions (D7140 x 5), the extractions (D7210 x 13), the alveoloplasty in conjunction with an extraction (D7310 x 2), the removal of the torus mandibularis (D7473 x 2), and the unlisted removable prosthodontic service (D5899 x 2) provided on May 18, 2020 by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pain injection.

You asked the Plan to pre-approve the injection. You say that you are in extreme pain. You say that this treatment has worked for you in the past. You say that you have spinal disease. You say that you have done physical therapy but the pain has not improved. You also say that this is the only long term treatment that takes away your pain. The Plan denied your request. The Plan says the documentation provided do not show that the required time frames are being followed. The Plan also says that the requested injection is not medically necessary.

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 the injection. Our reviewer says that the service is not medically necessary. Our physician reviewer found there is no role for a series of SI injections or scheduling injections in advance of significant symptoms. The reviewer found that the provided documentation shows that this is not an evidence-based approach. Therefore, the requested procedure is 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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a pain injection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 4 implants (D6010) and non-intravenous conscious sedation (D9248).

You asked the Plan to pre-approve the dental services. You say that you have had nothing but trouble with dentures. You also say that if you do not get the implants then you do not have any other options. The Plan denied your request. The Plan says implants are not listed as a covered service. The Plan also says non-intravenous conscious sedation is not listed as a covered 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.

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 4 implants (D6010) and non-intravenous conscious sedation (D9248).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ultrasound, transrectal approach provided to the enrollee on 
April 20, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says Medicare billing criteria are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 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 this service. Our reviewer says that Medicare billing criteria are not met. Our physician 
reviewer found the records provided do not support the services billed. The medical records provided do not 
include documentation to specifically identify that an ultrasound, transrectal (76872) was performed. We 
looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pay for ultrasound, transrectal approach provided to the enrollee on April 20, 2020.
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 foot and knee pain. 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of torus mandibularis (D7473). 
 
You asked the Plan to pre-approve the dental service. You say that you need this service so that you can get 
dentures. The Plan denied your request. The Plan says removal of torus mandibularis is not listed as a covered 
service. The Plan also says any services not listed 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 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. The Evidence of Coverage clearly states that any services not listed are 
not covered. Therefore, we decided that the Plan does not have to pre-approve removal of torus mandibularis 
(D7473).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown and core buildup provided on June 8, 2020. 
 
You asked the Plan to pay for the crown and core buildup. You say that you were never notified of the change 
in insurance. You say that the balance of the bill should be paid. The Plan denied your request. The Plan says 
the services are not covered benefits. 
 
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 pay for the crown 
and core buildup provided on June 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of torus mandibularis (D7473 x 2). 
 
You asked the Plan to pre-approve the dental services. You say that you need this procedure done so that you 
can eat. You also say that you need it so that you can get your dentures. The Plan denied your request. The Plan 
says removal of torus mandibularis is not listed as a covered service. The Plan also says any services not listed 
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 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. The Evidence of Coverage clearly states that any services not listed are 
not covered. Therefore, we decided that the Plan does not have to pre-approve the removal of torus 
mandibularis (D7473 x 2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the upper partial denture-flexible base.
You asked the Plan to pre-approve the upper partial denture-flexible base. You say that sickness affected your bones and denture. You say that it is not recommended to use metal in your mouth. The Plan denied your request. The Plan says the 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. Therefore, we decided that the Plan does not have to pre-approve the upper partial denture-flexible base.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the crown (D2740). 
 
You asked the Plan to pre-approve the crown (D2740). You say that you require a crown for tooth #11. The 
Plan denied your request. The Plan says the 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 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 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
crown (D2740).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation feature for a power wheelchair. 
 
You asked the Plan to pre-approve power seat elevation feature. You say that you are appealing. The Plan 
denied your request. The Plan says the denial of authorization for this device is correct, because a power seat 
elevation feature is not covered by Medicare. The Plan also says that they have approved the power wheelchair 
and all other options/accessories, so only the power seat elevation feature remains denied. 
 
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature is not covered by 
Medicare because it is not primarily medical in nature.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of power seat elevation feature have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a power seat elevation feature for a power wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cone beam CT capture and interpretation. 
 
You asked the Plan to pre-approve the cone beam CT capture and interpretation. You say that the enrollee 
needs a CT scan to discover if they have any additional roots present to continue treatment. 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. Therefore, we decided that the Plan does not have to pre-approve a 
cone beam CT capture and interpretation.
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 the IRF care is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.

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 the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the apicoectomy (D3410) for tooth #11.

You asked the Plan to pre-approve the apicoectomy (D3410). You say that the procedure is needed in order to be able to eat. You say that the dentist thinks this is the best way to be able to keep your tooth. The Plan denied your request. The Plan says the 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. Therefore, we decided that the Plan does not have to pre-approve the apicoectomy (D3410) for tooth #11.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the upper and lower partial denture (D5213 and D5214).

You asked the Plan to pre-approve the upper and lower partial denture (D5213 and D5214). You say that the dentures do not fit properly. You say that a new set of dentures is necessary if you want to be able to eat again. The Plan denied your request. The Plan says dentures are only covered one procedure every five plan years.

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, you also have a maximum benefit of one upper and lower partial denture every five plan years. The Plan paid for an upper and lower partial denture provided on February 19, 2020, which exhausted your benefit. Therefore, we decided that the Plan does not have to pre-approve the upper and lower partial denture (D5213 and D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete mandibular denture (D5120). 
 
You asked the Plan to pre-approve the complete mandibular denture. You say that you have no bottom teeth 
and can barely eat. You also say that you should not have to wait 5 years for a replacement. The Plan denied 
your request. The Plan says this service exceeds the coverage for one procedure every 5 years. 
 
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, complete mandibular denture (D5120) 
is limited to one procedure every five plan years. The record shows that you received a complete mandibular 
denture (D5120) on November 21, 2019, and your complete mandibular denture (D5120) benefit has been 
exhausted. Therefore, we decided that the Plan does not have to pre-approve a complete mandibular denture 
(D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the crown (D2751) and core buildup (D2950) for tooth 
#3. 
 
You asked the Plan to pre-approve the crown (D2751) and core buildup (D2950). You say that the dentist only 
did x-rays and did not fix your teeth. You say that the crown should be authorized. The Plan denied your 
request. The Plan says the service is covered one procedure per tooth every five years. 
 
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, you also have a maximum benefit of 
one crown and core buildup per tooth every five plan years. The Plan paid for a crown and core buildup for 
tooth #3, which exhausted your benefit. Therefore, we decided that the Plan does not have to 
pre-approve the crown (D2751) and core buildup (D2950) for tooth #3.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested physician's services.
You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says there are participating provider 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the requested physician's services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom fabricated abutment (D6057) and an abutment 
supported porcelain fused to metal crown (D6059). 
 
You asked the Plan to pre-approve the custom fabricated abutment and abutment supported porcelain fused to 
metal crown. You say that there is a medical and dental necessity to continue and finish the implant prosthetic 
treatment. The Plan denied your request. The Plan says these services are not covered under the enrollee's 
benefit package. 
 
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 a 
custom fabricated abutment (D6057) and an abutment supported porcelain fused to metal crown (D6059).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a prefabricated post and core in addition to crown. 
 
You asked the Plan to pay for the post and core. You say that you have an oral procedure scheduled for codes 
that have been already approved, and you need this additional service reviewed and approved. 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 pay for a 
prefabricated post and core in addition to crown.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown for tooth #4. You asked the Plan to pre-approve the crown. The Plan denied your request. The Plan says this service exceeds the benefit allowance.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, crowns are limited to once per 60 months per tooth. The record shows that you received a crown on tooth #4 on July 18, 2018, and your crowns benefit for tooth #4 has been exhausted. Therefore, we decided that the Plan does not have to pre-approve a crown for tooth #4.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.
You asked the Plan to pre-approve a continuous glucose monitor. You say that you have to prick your fingers many times daily so a CGM is a better alternative for you. The Plan denied your request. The Plan says your provider has stated you are not receiving three or more insulin injections per day and did not submit documentation that you are testing four or more times a day.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Provider documentation was not submitted showing that you are insulin treated three or more times a day, or that you test four or more times a day, so you do not meet the Medicare coverage criteria for a CGM. Based on this information, we decided that Medicare rules for coverage of a continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.