Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a limited view bone scan. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested service is not covered by Medicare or the health plan. 
 
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 scan. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that you have a history of breast cancer, and likely new metastatic disease. There is an order for 
limited bone scan placed during an encounter on 2/17/23. The information supplied prior to receiving records 
indicates the patient has had a complete bone scan on 2/23/23 but no report of same is in the submitted records. 
If such a scan has been done, the requested limited bone scan - procedure code 78300 - would not be medically necessary since a complete bone scan would have provided the required information. No report from the 
complete bone scan mentioned above is in the submitted records. 
 
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 scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a limited view bone scan.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 4 power wheelchair (K0884) and accessories. 
 
You asked the Plan to pre-approve the power wheelchair and accessories. You say that the requested power 
wheelchair is medically necessary. The Plan denied your request. The Plan says that a Group 4 power 
wheelchair is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that a Group 4 power wheelchair has added 
capabilities that are not needed for use in the home and will be denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. Per Medicare, a Group 4 power wheelchair is not covered. Since the 
power wheelchair is not covered, the requested accessories are also not covered. Therefore, we decided that the 
Plan does not have to pre-approve a Group 4 power wheelchair (K0884) and accessories.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-ambulance transportation. 
 
You asked the Plan to pre-approve the non-ambulance transportation. You say that the enrollee needs to see the 
doctor for follow-ups and to check her condition due to a broken hip. The Plan denied your request. The Plan 
says non-emergency chair car transportation is not a covered benefit by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport 
services.  
 
The services you have asked the Plan to pay for are wheelchair van transport services. Medicare will not pay 
for transport by wheelchair vans because wheelchair vans are vehicles that do not meet these requirements. 
Therefore, we decided that the Plan does not have to pre-approve non-ambulance transportation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve semi-precision abutment  placement (D6191) and 
semi-precision attachment  placement (6192). 
 
You asked the Plan to pre-approve semi-precision abutment and attachment. You say that this should be 
covered. The Plan denied your request. The Plan says these are not covered 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, 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 
semi-precision abutment  placement (D6191) and semi-precision attachment  placement (6192).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a Freestyle GCM. You say that the enrollee would benefit from a Freestyle 
CGM. The Plan denied your request. The Plan says only the preferred brand products listed in the EOC are 
covered. 
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for a Freestyle GCM. Therefore, we decided that the Plan does not have to pre-approve a Freestyle continuous 
glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of implant body: endosteal implant 
(D6010), bone graft at time of implant placement (D6104), deep sedation/general anesthesia  first 15-minutes 
(D9222), deep sedation/general anesthesia  each subsequent 15-minute increment (D9223) and therapeutic 
parenteral drugs, two or more administrations, different medications (D9612). 
 
You asked the Plan to pre-approve dental services. You say that you do not agree with the denial of services. 
The Plan denied your request. The Plan says this service is not covered under your 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. D6010, D6104, D9222, 
D92223 and D9612 are not covered under the Plans dental benefits. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D6010, D6104, D9222, 
D92223 and D9612 are not among those covered under this benefit. Therefore, we decided that the Plan does 
not have to pre-approve surgical placement of implant body: endosteal implant (D6010), bone graft at time of 
implant placement (D6104), deep sedation/general anesthesia  first 15-minutes (D9222), deep 
sedation/general anesthesia  each subsequent 15-minute increment (D9223) and therapeutic parenteral drugs, 
two or more administrations, different medications (D9612).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone replacement grafts (D7953). 
 
You asked the Plan to pre-approve the dental services. You say that you are suffering from stomach issues due 
to poor mastication. You say you need the denied procedure in order to have dentures made. The Plan denied 
your request. The Plan says the service at issue is not a listed 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 bone 
replacement grafts (D7953).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mandibular partial denture (D5214). 
 
You asked the Plan to pre-approve the dental services. You are asking for reconsideration for the denial of a 
partial denture. 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 a mandibular partial denture was exhausted on date of service November 11, 2022. 
Therefore, we decided that the Plan does not have to pre-approve a mandibular partial denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve abutment supported porcelain/ceramic crown (D6058). 
 
You asked the Plan to pre-approve the dental services. You say that this should be 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. Therefore, we decided that the Plan does 
not have to pre-approve abutment supported porcelain/ceramic crown (D6058).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crown - porcelain/ceramic (D2740) Tooth #5 and core 
buildup, including any pins when required (D2950) Tooth #5. 
 
You asked the Plan to pre-approve dental services. You say that you do not agree with the denial of the 
requested services. The Plan denied your request. The Plan says the services are not covered under your 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. Crown - porcelain/ceramic 
(D2740) and core buildup, including any pins when required (D2950) are not covered under the Plans dental 
benefits. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D2740 and D2950 are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
crown - porcelain/ceramic (D2740) Tooth #5 and core buildup, including any pins when required (D2950) 
Tooth #5.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services. 
 
You asked the Plan to pre-approve the dental services. You say that you would like an exception to see the 
OON provider. The Plan denied your request. The Plan says dental services from an out-of-network provider 
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. 
 
You are requesting 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 pre-approve dental 
services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve maxillary partial denture - cast metal framework with 
resin denture bases (including retentive/clasping materials, rests, and teeth) (D5213). 
 
You asked the Plan to pre-approve the dental services. You say that you lost your dentures, so you need to get 
new ones. 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. This benefit includes the 
requested maxillary partial denture - cast metal framework with resin denture bases (including retentive/ 
clasping materials, rests, and teeth) (D5213) but is limited to one procedure per 60 floating months. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows you received covered D5213 on April 11, 2019; therefore, your benefit has been exhausted. Therefore, 
we decided that the Plan does not have to pre-approve maxillary partial denture - cast metal framework with 
resin denture bases (including retentive/clasping materials, rests, and teeth) (D5213).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete upper denture (D5110) and partial lower 
denture (D5214). 
 
You asked the Plan to pre-approve the dental services. You say that you lost your dentures and need new ones. 
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. This benefit includes the 
requested complete upper denture (D5110) and partial lower denture (D5214) but is limited to once every 60 
months. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested D5110 and D5214 was exhausted on date of service November 30, 2022. 
Therefore, we decided that the Plan does not have to pre-approve complete upper denture (D5110) and partial 
lower denture (D5214).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for arthrotomy, with synovectomy, knee; anterior AND posterior 
including popliteal area rendered on August 23, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the code cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 In this case, the CPT Code Manual definition of code 27335 is "Arthrotomy, with synovectomy, knee; anterior 
AND posterior including popliteal area." 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the procedure details cite the 
patella was inverted and the anterior fat pad was excised along with some hypertrophic synovitis. The 
hypertrophic synovium on the distal end of the femur was debrided. These were performed to prepare the knee 
for the implant/total knee. Therefore, the records do not support CPT 27335: arthrotomy with synovectomy, 
knee, anterior AND posterior including popliteal area as a separate and distinct procedure from CPT 27447: 
arthroplasty, knee, condyle and plateau; medial AND lateral compartments with or without patella resurfacing 
(total knee arthroplasty). 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for arthrotomy, with synovectomy, knee; anterior AND posterior including popliteal area rendered 
on August 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Matrion placental membrane skin substitute. 
 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no chronic healing wound. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that in this particular case the two progress notes enclosed advise that the patient has undergone wound 
debridement of the right hallux. The enrollee has also undergone dressings and treated with oral antibiotics. It 
is unclear as to whether the patient is non-weight-bearing at this point. Although placental membrane grafts are Food and Drug Administration (FDA) approved for diabetic and venous stasis ulcerations, it does not appear 
that this patients wound has been treated long enough or with non weight bearing, to allow for application of 
advanced treatments like placental skin substitute. It does not appear reasonable to apply a placental skin 
substitute at this point, when further debridement, offloading, dressings, and oral antibiotics are still allowing 
for improvement of the ulceration. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Matrion placental membrane skin substitute.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient mental health treatment. 
 
You asked the Plan to pre-approve outpatient mental health treatment. You say that the services are necessary. 
The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
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 outpatient mental health treatment. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found based on the information provided, this enrollee does not require intensive 
outpatient treatment as being medically necessary or reasonable and could be treated in a lesser restrictive 
environment as she is not showing intensity to meet the level of care requested.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of outpatient mental health treatment have not been met. Therefore, we decided 
that the Plan does not have to pre-approve outpatient mental health treatment.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sinus augmentation (D7951) for tooth #3 and #4. 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denied dental 
services. The Plan denied your request. The Plan says the denial of authorization for these services is correct, 
because the sinus augmentation is not covered by the 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 sinus 
augmentation (D7951) for tooth #3 and #4.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incisional biopsy of oral tissue- hard (D7285) and 
incisional biopsy of oral tissue- soft (D7286). 
 
 
You asked the Plan to pre-approve incisional biopsy of oral tissue. You say that this should be covered. The 
Plan denied your request. The Plan says these are not covered 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, 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 
incisional biopsy of oral tissue- hard (D7285) and incisional biopsy of oral tissue- soft (D7286).