Persius/hicric huggingface dataset:
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 this is medically necessary. The Plan denied 
your request. The Plan says the guidelines say that this item is covered if it is part of a covered leg brace, or if it 
is used to prevent and treat diabetic foot ulcers. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sleeve gastrectomy. 
 
You asked the Plan to pre-approve sleeve gastrectomy. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that sleeve gastrectomy is only covered for certain 
indications. 
 
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 sleeve gastrectomy. Our reviewer says 
that the documentation does not support that the requested services are not medically necessary. Our physician 
reviewer found the documentation shows that the enrollee has a body mass index (BMI) above 35 kg/m2. 
However, there is no documentation of a weight associated co-morbid condition such as refractory 
hypertension, sleep apnea or diabetes. Therefore, the enrollee does not meet criteria for the requested 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 sleeve gastrectomy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve sleeve gastrectomy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transfer bench. 
 
You asked the Plan to pre-approve the bench. You say that you are at risk for a fall. The Plan denied your 
request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a transfer bench.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that you are unable to stand and you are off balance 
due to your weight. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a porcelain/ceramic crown for teeth 7, 8, 9, and 10.
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 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. The Plan covers these services when the services are medically necessary and reasonable. 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 do not meet the criteria for coverage. Our physician reviewer found the submitted dental records and x-rays do not provide any evidence of a substantial breakdown of the crown of the teeth from cavities or fracture. The criteria for coverage of the requested crowns are not met and the services are not reasonable or medically necessary. We looked at this physician's review, the file, and Medicare rules. 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 pre-approve a porcelain/ceramic crown for teeth 7, 8, 9, and 10.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the removal of torus mandibularis (D7473) provided on March 26, 2019.You asked the Plan to pay for the dental service. You say that you received authorization for the service. You say that you cannot afford the cost of this procedure. You also say that the authorization for the service should be honored.The Plan denied your request. The Plan says the removal of torus mandibularis 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 removal of the torus mandibularis is not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay for the removal of torus mandibularis (D7473) provided on March 26, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), and the prophylaxis (D1110) provided on August 21, 2019.

You asked the Plan to pay for the dental services. You say that you went to the dentist previously and everything was okay. You say that you went again on August 21, 2019 and were advised that the provider was not in network. The Plan denied your request. The Plan says services received out of network are not covered. The Plan says that the dentist in this case is not a network provider. The Plan also says that plan confirmed with the provider office that the enrollee was notified prior to the services being rendered that the provider was out of network.

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, services received out of network are not covered. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120), and the prophylaxis (D1110) provided on August 21, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on May 14, 2019.
You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that you were given a list of approved dentists but so few were provided, and none were acceptable or convenient for you. You also say that you decided to use your long-standing dentist who is reasonable. The Plan denied your request. The Plan says non-emergency services provided by an out-of-network provider are not available with your dental plan.
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 covered when they are received out-of-network. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on May 14, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvediagnostic casts (D0470).You asked the Plan to pre-approvethese services. You say that the current treatment in need ofauthorization is to allow the patient to have proper occlusion and eating abilities.The Plan denied your request. The Plan says these services are not a covered benefit under the enrollee's contractual dental policy.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 requestedservices are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvediagnostic casts (D0470)
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea core buildup, including any pins when required (D2950) for tooth number 9.You asked the Plan to pre-approvea core buildup. You say that the enrollee hit the front of her mouth and cracked her tooth. You feel that the toothwould be better treated with a crown to extend thelongevity.The Plan denied your request. The Plan says the service requested is not a covered benefitunder the enrollee's contractual dental policy.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 Planoffers a dental benefit in excess of Medicare coverage, the requested service is not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approve a core buildup, including any pins when required (D2950) for tooth number 9
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and the palliative
(emergency) treatment of dental pain, minor, (D9110) provided on September 23, 2019.
You asked the Plan to pay for the dental services. You say that you called around your area to find a dentist that
took your insurance. You say that you were then told the provider was out of network. You also say you are
confused as you have been to this provider 4 times and the bill you received was only for $158. The Plan
denied your request. The Plan says dental services received 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 Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the dental services you received are not
covered when you receive them out of network. The Customer Handbook clearly states that if you
receive services from an out of network dentist, you will be responsible for all costs related to those services.
Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and
the palliative (emergency) treatment of dental pain, minor, (D9110) provided on September 23, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe mandibular partial denture (D5214).You asked the Plan to pre-approvethe mandibular partial denture. You say that your current upper denture no longer fits correctly because of physical changes. You also say that you need a lower denture because you have been using the left side of your mouth to chew, which is causing you pain.The Plan denied your request. The Plan says this denture is not medically necessary for you.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 mandibular partial denture when the services are medically necessary and reasonable. 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 mandibular partial denture. Our reviewer says that the denture is not medically necessary. Our physician reviewer found that the Policy stipulates that eight posterior teeth in contact (four sets) is generally acceptable for functional purposes. Our reviewer found that in this instance there are fourteen teeth in contact for a total of seven sets of contacting teeth. There is minimal improvement in function to be gained by the addition of a lower partial denture which would replace one lower tooth. Our physician reviewer also found that given the Plan criteria, and the lack of significant improvement from an additional appliance, there is no medical necessity for the requested lower partial denture.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the mandibular partialdenture have not been met.Therefore, we decided that the Plan does not have to pre-approvethe mandibular partial denture (D5214)
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120 x 2), prophylaxis (D1110 x 2), and 1 surface silver filling (D2140) provided from March 5, 2019 to September 9, 2019 by the out of network dentist.
You asked the Plan to pay for the dental services. You say that you were given a list of in network dentists. You say there were so few options and none of them were acceptable or convenient. You say that you continued with your long standing dentist. You say that the services should be paid at the in network rate. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says dental services received 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 Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the services you received are not covered when you receive them out of network. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120 x 2), prophylaxis (D1110 x 2), and 1 surface silver filling (D2140) provided from March 5, 2019 to September 9, 2019 by the out of network dentist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the bone replacement graft (D4263).
You asked the Plan to pre-approve the bone replacement graft (D4263). You say that you want to appeal the denial. The Plan denied your request. The Plan says this 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 bone replacement graft (D4263).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for Dental services (D9230, D7210) provided August 8, 2019 to August 29, 2019 by out-of-network provider.
You asked the Plan to pay for the out-of-network dental services. You say that the services were medically necessary and should be covered. The Plan denied your request. The Plan says out-of-network dental services are 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 pay for Dental services (D9230, D7210) provided August 8, 2019 to August 29, 2019 by out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core build up (D2950) and gum surgery (D4212).
You asked the Plan to pre-approve the core build up and gum surgery. The Plan denied your request. The Plan
says core build up and gum surgery are not listed as covered services.
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 core build up and gum surgery are
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve
core build up (D2950) and gum surgery (D4212).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the topical application of fluoride (D1208), prefabricated post and core in addition to a crown (D2954), and the endodontic therapy of an anterior tooth (D3310).
You asked the Plan to pre-approve the dental services. You say that the crown is necessary because it is broken and can be saved. The Plan denied your request. The Plan says the topical application of fluoride is not listed as a covered service. The Plan says that post and core in addition to a crown is not listed as a covered service. The Plan also says that endodontic therapy for an anterior tooth is listed as a non-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 the topical application of fluoride (D1208), prefabricated post and core in addition to a crown (D2954), and the endodontic therapy of an anterior tooth (D3310).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete mandibular overdenture (D5865).
You asked the Plan to pre-approve the dental service. You say that you need this service as soon as possible.
The Plan denied your request. The Plan says the overdenture is not 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 overdenture is not among those
covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a complete
mandibular overdenture (D5865).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation, panoramic x-ray, and two extractions provided on July 31, 2019 and August 7, 2019
.
You asked the Plan to pay for the problem focused limited oral evaluation, panoramic x-ray, and extractions. You say that you were in severe pain and needed two teeth extracted. The Plan denied your request. The Plan says non-emergency services provided by an out-of-network provider are not available with your dental plan.

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 covered when they are received out-of-network. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation, panoramic x-ray, and two extractions provided on July 31, 2019 and August 7, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core buildup (D2950).
You asked the Plan to pre-approve core buildup (D2950). You say that you would like the Plan to reconsider
their denial. The Plan denied your request. The Plan says core buildup (D2950) is not a covered dental 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 core buildup (D2950) is
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve
core buildup (D2950).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core build up on tooth #14 (D2950) and periodontal scaling-4 quadrants (D4341).

You asked the Plan to pre-approve core build up on tooth #14 (D2950) and periodontal scaling-4 quadrants (D4341). You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says core buildup (D2950) is not a covered benefit under Medicare or the plan. The plan states periodontal scaling is covered under the plan's supplemental dental benefit, but is limited to only one time in a 24 month period. The plan states you received periodontal scaling (D4341) in September 2019, which is less than 24 months ago.

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 core build up (D2950) is not among those covered under this benefit. Furthermore, though the Plan covers periodontal scaling (D4341) under the Plan's supplemental dental benefit, the request for periodontal scaling (D4341) in this case is not covered. The Plan's contract clearly states periodontal scaling is only covered once every 24 months. The file shows you received periodontal scaling in September 2019, which is less than 24 months ago. Therefore, we decided that the Plan does not have to pre-approve core build up on tooth #14 (D2950) and periodontal scaling-4 quadrants (D4341).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core build up (D2950) for tooth # 3.
You asked the Plan to pre-approve the core build up for tooth # 3. You say that tooth # 3 has extensive carries undermining the MB cusp leading to fracture. The Plan denied your request. The Plan says core build up 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, core build up is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core build up (D2950) for tooth # 3.