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

 
We decided that the Plan does not have to pre-approve a crown - porcelain fused to predominantly base metal 
(D2751). 
 
You asked the Plan to pre-approve the crown - porcelain fused to predominantly base metal (D2751). The Plan 
denied your request. The Plan says there is no clinical evidence to support medical necessity. 
 
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 the crown - 
porcelain fused to predominantly base metal (D2751) 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 crown - porcelain fused to 
predominantly base metal (D2751). Our reviewer says that the documentation does not support the request for 
crowns on tooth #24 and #25.  Our physician reviewer found the criteria has not been met for replacement crowns as tooth #24 is part of a 
three unit bridge and cannot be replaced with a single crown, is not otherwise defective, and tooth #25 is an 
existing crown that does not have any apparent defect. In order to replace an existing full coverage restoration 
there must be some defect that compromises the integrity of the crown. 
 
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 crown - porcelain fused to predominantly base metal (D2751) have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a crown - porcelain fused to 
predominantly base metal (D2751).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gingival irrigation. 
 
You asked the Plan to pre-approve gingival irrigation. You say that the services requested are medically 
necessary. 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 
gingival irrigation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injection identified with code 64492. 
 
You asked the Plan to pre-approve facet joint injection identified with code 64492. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says the requested services are not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a maximum of two levels can be performed on 
the spine.  
 
We looked at the file and Medicare rules. Review of the file shows that two levels are being approved by the 
Plan. The request for a third level is not a covered benefit. Based on this information, we decided that Medicare 
rules for coverage of facet joint injection identified with code 64492 have not been met. Therefore, we decided 
that the Plan does not have to pre-approve facet joint injection identified with code 64492.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377, E2313, E2311). 
 You asked the Plan to pre-approve an expandable controller. You say that this device is medically necessary 
for the enrollee's condition. The Plan denied your request. The Plan says there is no medical need for the 
requested expandable controller. 
 
The Plan follows Medicare rules. Medicare rules say that an expandable controller is subject to the criteria 
listed in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an expandable controller. Our reviewer 
says that the requested expandable controller is not medically reasonable and necessary. Our physician 
reviewer found that based on the medical records provided there is no documentation that the expandable 
controller, harness and electronic connection are necessary for the enrollees condition. Provided records 
document that the enrollee has "fair" left upper extremity strength and is independent with eating after set-up 
thus indicating she has adequate upper extremity strength and function to operate the wheelchairs power 
options with 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 have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an expandable controller (E2377, E2313, E2311).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve psychotherapy visits (90834, 90837) to be provided by 
an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve psychotherapy visits. You say that you would like to continue treatment 
with your current provider. You have tried an in-network provider but was only seen every 2 weeks and was 
not helpful. The Plan denied your request. The Plan says the requested service is available in-network. There 
are no extenuating circumstances related to geographic access, reasonable continuity of care, or unique 
medically recognized qualifications of the requested out-of-network provider to justify prior authorization of 
out-of-network benefits beyond the transition of care allowance. 
 
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 records show the Plan partially 
approved 3 transition of care visits. 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 psychotherapy visits (90834, 
90837) to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for scaling in gingival inflammation (D4346) provided by a 
participating provider. 
 
You asked the Plan to pay for scaling in gingival inflammation. You say that you would like the Plan to 
approve this service. The Plan denied your request. The Plan says the requested service is not a covered dental 
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 pay for scaling in 
gingival inflammation (D4346) provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a consultation (D9310) provided on March 18, 2022. 
 
You asked the Plan to pay for a consultation. You say that you disagree with the denial of dental services. The 
Plan denied your request. The Plan says a consultation (D9310) is not covered by the enrollee's dental 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 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
consultation (D9310) provided on March 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a resin-based composite (D2330). 
 
You asked the Plan to pre-approve a resin-based composite. You say that you would like to appeal this service. 
The Plan denied your request. The Plan says this service is not covered under your benefit plan. 
 
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 a 
resin-based composite (D2330).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the occlusal orthotic device (D7880) provided on April 6, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the occlusal orthotic device. You say that there are no dentist's that are in-
network with the Plan, and it was impossible to comply with the Plan's rules. You also say that you would like 
to be reimbursed for this necessary medical expense. The Plan denied your request. The Plan says services 
from non-participating providers are not covered under your plan unless they are authorized by the Plan before 
the services are provided. 
 
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 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 the occlusal orthotic device (D7880) provided on 
April 6, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental services. 
 
You asked the Plan to pre-approve the dental services. You say that you would like to request reconsideration 
of the denied authorization. The Plan denied your request. The Plan says an allowance for fixed bridges is 
available, however, coverage is limited to anterior maxillary three-unit bridges (one missing maxillary tooth), 
and anterior mandibular bridges up to four units (two missing adjacent mandibular teeth). Bridges will only be 
covered if no other teeth are missing in the same arch other than 
3rd molars. 
 
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 
dental services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on May 
23, 2022. 
 
You asked the Plan to pay for the dental services. You say that you changed to a new dentist. The Plan denied 
your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service November 30, 2020. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
provided on May 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on August 2, 
2022. 
 
You asked the Plan to pay for the periodontal maintenance. You say that you thought you were entitled to two 
more cleanings. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service April 15, 2022. 
Therefore, we decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on 
August 2, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two physical therapy visits. 
 
You asked the Plan to pre-approve therapy visits. You say that mobilization and strengthening have been 
performed with good results. The Plan denied your request. The Plan says the remaining two visits are not 
medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy visits. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that the additional four visits are sufficient to establish a home 
exercise program. The enrollee has reached a high level of function with their lumbar spine. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of therapy visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve two physical therapy visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone graft (D6104) provided on October 4, 2021. 
 
You asked the Plan to pay for a bone graft. You say that the service was necessary. The Plan denied your 
request. The Plan says the service at issue 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 pay for a bone 
graft (D6104) provided on October 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the palliative (emergency) treatment of dental pain (D9110) 
and resin-based composite (D2335) on tooth #10, and to pay more for the resin-based composites (D2335) on 
tooth #'s 8 and 9 provided on April 11, 2022, by an out-of-network (OON) provider. 
 
  You asked the Plan to pay for the palliative (emergency) treatment of dental pain and one resin-based 
composite, or pay more for the resin-based composites on tooth #'s 8 and 9. You say that you did not have time 
to find an in-network provider because you needed immediate help. The Plan denied your request. The Plan 
says the palliative (emergency) treatment of dental pain is not a covered expense under your dental plan. The 
Plan says that your benefits for the one resin-based composite has been satisfied and the frequency limitation 
has been exceeded. The Plan also says that these services were performed by a non-participating provider, and 
you are responsible for any difference between the Maximum Allowable Fee and the amount the provider bills 
you for the services. 
 
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, palliative (emergency) treatment of 
dental pain (D9110) is not among those covered under this benefit. The record shows that your restorations 
benefit was exhausted on April 11, 2022. You are also responsible for a 55% coinsurance for each covered 
resin-based composite, plus the difference between the billed and allowed amounts because these services were 
received OON. Therefore, we decided that the Plan does not have to pay for the palliative (emergency) 
treatment of dental pain (D9110) and resin-based composite (D2335) on tooth #10, and to pay more for the 
resin-based composites (D2335) on tooth #'s 8 and 9 provided on April 11, 2022, by an out-of-network (OON) 
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an upper denture and lower denture. 
 
You asked the Plan to pre-approve an upper denture and lower denture.. You say that the services requested are 
medically necessary. 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 an 
upper denture and lower denture.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve therapeutic parenteral drugs (D9610), bone replacement 
grafts on tooth #16, 18, and 19 (D4263), and osseous surgery (D4260). 
 
You asked the Plan to pre-approve the dental services. You say that you disagree with the denial of dental 
services. The Plan denied your request. The Plan says therapeutic parenteral drugs (D9610), bone replacement 
grafts (D4263), and osseous surgery (D4260) are not covered by your routine dental 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 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
therapeutic parenteral drugs (D9610), bone replacement grafts on tooth #16, 18, and 19 (D4263), and osseous 
surgery (D4260).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120) and prophylaxis (D1110) 
provided on December 28, 2021. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says the dental services were received from an out-of-network provider 
and are not covered by your supplemental 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. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a periodic oral evaluation (D0120) and prophylaxis (D1110) provided on December 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), intraoral x-rays 
(D0210), and a panoramic x-ray (D0330) provided on December 20, 2021. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says your benefit for the requested items or services has already been 
exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested items or services was exhausted on date of service September 6, 2019. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), 
intraoral x-rays (D0210), and a panoramic x-ray (D0330) provided on December 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) 
provided on June 1, 2022. 
 
You asked the Plan to pay for the problem focused limited oral evaluation. You say that this service should 
have been covered. The Plan denied your request. The Plan says your benefit for the requested item or service 
has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service March 2, 2022. 
Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation 
(D0140) provided on June 1, 2022.