Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve prosthetic advanced foot and ankle feature.
You asked the Plan to pre-approve prosthetic advanced foot and ankle feature. You say that the requested prosthetic equipment is medically necessary. The Plan denied your request. The Plan says the criteria for coverage 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 prosthetic advanced foot and ankle feature. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the criteria listed in the LCD for the requested prosthetic advanced foot and ankle feature have not been met. Additionally, the criteria per the Social Security Act, Section 1862 (a)1(A) and the 42 CFR 411.15(k), have not been met as Medicare does not pay for any items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. The requested items exceed the patient's medical need. The physician medical progress notes and the physician prescription do not support that this patient requires a K3 level prosthesis. Therefore, the request for the advanced foot and ankle feature is not medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of prosthetic advanced foot and ankle feature have not been met. Therefore, we decided that the Plan does not have to pre-approve prosthetic advanced foot and ankle feature.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and periapical x-ray 
(D0220) provided on October 13, 2021. 
 
You asked the Plan to pay for the dental services. You say that these services should be covered. The Plan 
denied your request. The Plan says services are only covered when received by a participating provider. 
 
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, dental services received by a 
nonparticipating provider are not among those covered under this benefit. Therefore, we decided that the Plan 
does not have to pay for the limited oral evaluation (D0140) and periapical x-ray (D0220) provided on October 
13, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the clinical value and effectiveness of bone marrow aspirate in the 
setting of spinal fusion surgery has not been demonstrated in the peer-reviewed literature. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Bone marrow 
aspirate remains experimental. More research is needed when used as bone graft in spinal surgery. Our 
physician reviewer found that the enrollee's condition does not meet criteria for coverage of these services. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve bone marrow aspirate for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for seven extractions (D7140) provided on December 28, 2021. 
 
You asked the Plan to pay for extractions. You say that these services were necessary. The Plan denied your 
request. The Plan says this service is not covered by your 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 seven 
extractions (D7140) provided on December 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic x-ray (D0330), limited oral evaluation 
(D0140), general anesthesia (D9222, D9223) and surgical tooth extraction (D7210) provided on May 13, 2021. 
 
You asked the Plan to pay for the dental services. You say that you knew this provider was out-of-network, but 
do not understand why you cannot receive reimbursement for these services when out-of-network care is 
covered by your plan. The Plan denied your request. The Plan says the provider in this case does not participate 
in Medicare and therefore these services are not eligible for reimbursement. 
 
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 supplemental 
dental care when the services are performed by a licensed dental provider who has not opted out of Original 
Medicare. We looked at the file and the Plan's rules. The provider in this case does not participate in Medicare. Based on 
this information, we decided that the Plan's rules for coverage of the dental services have not been met. 
Therefore, we decided that the Plan does not have to pay for the panoramic x-ray (D0330), limited oral 
evaluation (D0140), general anesthesia (D9222, D9223) and surgical tooth extraction (D7210) provided on 
May 13, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the resin-based composite (D2335) provided on December 21, 2021. 
 
You asked the Plan to pay for the resin-based composite. You say that you would like to appeal this service. 
The Plan denied your request. The Plan says that this service is not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not provide a copy of the applicable 2021 Evidence of Coverage 
for this case. Without this information we cannot determine that the Plan's coverage rules support the denial of 
payment in this case, or that the enrollee has been adequately notified of the Plan's coverage rules and benefits. 
Consequently, the Plan has not substantiated their denial of payment in this case. Therefore, we decided that 
the Plan has to pay for the resin-based composite (D2335) provided on December 21, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac joint injection. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says it is 
considered to be experimental. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician 
reviewer found that the enrollee has a history of low back pain due to lumbosacral spondylosis without 
myelopathy or lumbar radiculopathy. According to the literature, sacral lateral nerve branch blocks and 
ablations for the diagnosis or treatment of sacroiliac joint mediated pain is considered experimental and 
investigational. Studies completed say that this procedure does not improve outcomes compared to standard 
treatment of sacroiliac joint pain. The review has determined that 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a sacroiliac joint injection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the re-evaluation, post-operative office visit (D0171) 
provided on October 21, 2021. 
 
You asked the Plan to pay for the re-evaluation. You say that this service was necessary. The Plan denied your 
request. The Plan says this service is not covered by your 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 the re-
evaluation, post-operative office visit (D0171) provided on October 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220), anterior resin-
based composite (D2331), posterior resin-based composite of one surface (D2391), and posterior resin-based 
composite of three surfaces (D2393) provided on December 15, 2021. 
 
You asked the Plan to pay for the first intraoral periapical x-ray and resin-based composites. You say that this 
was an emergency dental procedure because your tooth had ruptured. The Plan denied your request. The Plan 
says the first intraoral periapical x-ray is not a covered expense under your dental plan. The Plan also says that 
your benefits for the resin-based composites have been satisfied and the frequency limitation has been 
exceeded.  
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, first intraoral periapical x-ray (D0220) 
is not among those covered under this benefit. The contract says that restorations are limited to two procedure 
codes per calendar year. The record shows that you received two resin-based composites (D2332 x2) on 
January 7, 2021 which were covered by the Plan and your restorations benefit has been exhausted. Therefore, 
we decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220), anterior resin-
based composite (D2331), posterior resin-based composite of one surface (D2391), and posterior resin-based 
composite of three surfaces (D2393) provided on December 15, 2021.
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 mandibular partial denture. You say that your current denture has never 
fit properly and you have not been able to wear it. The Plan denied your request. The Plan says this service 
exceeds the maximum count allowed per period. 
 
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, mandibular partial denture (D5214) is 
limited to one procedure every five plan years. The record shows that you received a mandibular partial denture 
(D5214) on April 24, 2018 and your mandibular partial denture (D5214) benefit has been exhausted. 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 a comprehensive oral evaluation (D0150) and surgical 
extraction (D7210) to be provided by an oral surgeon. 
 
You asked the Plan to pre-approve the dental services. You say that your general dentist has referred you to an 
oral surgeon. You say that you were advised by a plan representative that this service is covered. You also say 
that you are on antibiotics and have pain when you chew. The Plan denied your request. The Plan says dental 
services must be performed by a participating general dentist. The Plan also says that dental services performed 
by an oral surgeon 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested services to be provided 
by an oral surgeon are not among those covered under this benefit. Therefore, we decided that the Plan does not 
have to pre-approve a comprehensive oral evaluation (D0150) and surgical extraction (D7210) to be provided 
by an oral surgeon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional intraoral periapical x-ray (D0230) provided on 
November 19, 2021. 
 
You asked the Plan to pay for the additional intraoral periapical x-ray. You say that you would like the Plan to 
consider paying for the x-ray because the service was good and professional. The Plan denied your request. The 
Plan says this service is allowed two times per calendar year. The Plan also says that you have reached the limit 
for this 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, you are limited to two of either codes 
D0220, D0230, D0270, D0272, D0273, or D0274 per 1 calendar year. The record shows that you received a 
first intraoral periapical x-ray (D0220) and bitewing x-rays (D0274) on November 19, 2021 and your intraoral 
x-rays and bitewing x-rays benefits have been exhausted. Therefore, we decided that the Plan does not have to 
pay for the additional intraoral periapical x-ray (D0230) provided on November 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a mandibular 
partial denture (D5214). 
 
You asked the Plan to pre-approve the complete maxillary denture and mandibular partial denture. You say that 
you need these dentures and would like them to be reconsidered for approval. The Plan denied your request. 
The Plan says these services are 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 
complete maxillary denture (D5110) and a mandibular partial denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the re-cement or re-bond crown (D2920) provided on July 
23, 2021. 
 
You asked the Plan to pay for the dental service. You say that your plan documents state that you would be 
covered on the date that you signed up for extra coverage. You say that you signed up for the optional 
supplemental dental rider on July 22, 2021. You say that a plan representative advised the rider would not take 
effect until July 30, 2021. You also say that you do not understand the delay of coverage. The Plan denied your 
request. The Plan says re-cement or re-bond crown is not listed as a covered service. The Plan also says that 
you did not become effective with the dental rider until after you received the service. 
 
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 re-cement or re-bond crown is not 
among those covered under this benefit. Additionally, the record shows that the optional supplemental dental rider was not effective until after you the date of service in this case. Therefore, we decided that the Plan does 
not have to pay for the re-cement or re-bond crown (D2920) provided on July 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MAKOplasty for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the clinical value and effectiveness of MAKOplasty (computer-
assisted surgical navigation) in the conjunction with total knee arthroplasty has not been demonstrated in the 
peer-reviewed literature. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Current evidence 
based medical literature does not support the routine use of computer-assisted navigated total knee arthroplasty 
over conventional total knee arthroplasty. Ultimate improved outcomes regarding functionality and pain relief have not been documented in large volume long-term studies. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception. Our physician 
reviewer found that the enrollee's condition does not meet criteria for coverage of these services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve MAKOplasty for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the repeat right SI joint injection (CPT code 27096). 
 
You asked the Plan to pre-approve the injection. You say that the service is necessary. The Plan denied your 
request. The Plan says the right-side block did not come close to meeting the Centers for Medicare & Medicaid 
Services (CMS) LCD. 
 
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 physician reviewer 
found there is no documentation provided indicating that the first right SI joint injection provided greater than 
or equal to 75% with the ability to perform previously painful maneuvers or that pain relief from therapeutic 
injections was greater than or equal to 50% with the continued ability to perform previously painful maneuvers 
for at least six (6) weeks. The review has determined that the medical records provided do not meet the 
requirements listed in Medicare's LCD. 
 
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 the repeat right SI joint injection (CPT code 27096).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve guided tissue regeneration (D4266), a surgical 
placement of an implant body (D6010), a prefabricated abutment, includes modification and placement 
(D6056) and an implant supported crown (D6066). 
 
You asked the Plan to pre-approve guided tissue regeneration, a surgical placement of an implant body, 
prefabricated abutment and an implant supported crown. You say that the enrollee has a tooth infection that is 
affecting his diabetes. The tooth should be replaced as soon as possible because the enrollee is not able to eat, 
and his food has to be blended. The Plan denied your request. The Plan says the requested services are not 
covered under the enrollee's benefit 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 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
guided tissue regeneration (D4266), a surgical placement of an implant body (D6010), a prefabricated 
abutment, includes modification and placement (D6056) and an implant supported crown (D6066).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placements of implant bodies: endosteal 
implants (D6010). 
 
You asked the Plan to pre-approve the endosteal implants. You say that dentures are not the best option for this 
enrollee because it can damage pre-existing teeth. You also say that certain foods cannot be eaten with 
dentures. The Plan denied your request. The Plan says this service is not covered under the enrollee's 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 
surgical placements of implant bodies: endosteal implants (D6010).