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

 
We decided that the Plan does not have to pre-approve a crown and maxillary partial denture. 
 
You asked the Plan to pre-approve a crown and maxillary partial denture. You say that you are appealing the 
denial. The Plan denied your request. The Plan says this service is not covered by the Plan'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 Plan's coverage rules apply in this case. The Plan covers a crown - full 
cast predominantly base metal (D2791) and maxillary partial denture (D5213) 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 a crown and maxillary partial denture. 
Our reviewer says that the requested treatment is not medically necessary this time. Our physician reviewer 
found the criteria has not been met for the crown or partial denture. The partial denture approval requires that 
there are no untreated cavities. Tooth #9 though requested for a crown restoration is not restorable and needs to 
be removed prior to any replacements with a removable appliance. Tooth #11 is broken down as well and needs 
to be addressed prior to consideration for 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 a crown and maxillary partial denture have not been met. Additionally, these 
services do not qualify for coverage under your medical benefits. Therefore, we decided that the Plan does not 
have to pre-approve a crown and maxillary partial denture.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) and a core build-up (D2950), provided 
by an out-of-network provider. 
 
You asked the Plan to pre-approve a crown and a core build-up. You say that these services are medically 
necessary. The Plan denied your request. The Plan says the requested services have been correctly denied. 
 
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 a crown and a 
core build-up 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 a crown and a core build-up. Our 
reviewer says that these services are not medically necessary. Our physician reviewer found the documentation 
that was provided does not show that the requested services have meet the medical criteria 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 a crown and a core build-up have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a crown (D2740) and a core build-up (D2950), provided by an out-of-
network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve partial mandibular overdenture (D5866). 
 
You asked the Plan to pre-approve overdenture. You say that this service is medically necessary. The Plan 
denied your request. The Plan says partial mandibular overdenture (D5866) is 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 
partial mandibular overdenture (D5866).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the brain. 
 
You asked the Plan to pre-approve an MRI of the brain. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an MRI of the brain. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found the requested service is not 
medically necessary and reasonable for the diagnosis and treatment for the enrollee's clinical condition at this 
time.  The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. 
 
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 MRI of the brain have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a magnetic resonance imaging (MRI) of the brain.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81407, 81479, 81286, 81408, 81404) provided 
November 23, 2021. 
 
You asked the Plan to pay for the lab services. You say that the service was medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that only the following codes should be billed for 
Cardiovascular Disease Screening: CPT code 80061 (Lipid panel) which includes CPT codes: 82465 
(Cholesterol, serum or whole blood, total), 83718 (Lipoprotein, direct measurement; high density cholesterol) 
and/or 84478 (Triglycerides). 
 
We looked at the file and Medicare rules. The codes billed for cardiovascular risk assessment testing are not 
eligible for coverage for cardiovascular disease screening. Based on this information, we decided that Medicare 
rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to 
pay for lab services (81407, 81479, 81286, 81408, 81404) provided November 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on January 27, 2022. 
 
You asked the Plan to pay for the testing services. You say that an updated certificate was provided. The Plan 
denied your request. The Plan says medical necessity is unable to be determined. 
 
 The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or 
provider must corroborate the documentation in the beneficiary's medical documentation. 
 
We looked at the file and Medicare rules. In this case, medical records were not provided to support the billed 
services. The file shows that the Plan made multiple attempts to obtain additional information without success. 
Based on this information, we decided that the Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pay for the lab services provided on January 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prostate artery embolization services. 
 
You asked the Plan to pre-approve prostate artery embolization services. You say that this procedure is 
medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this procedure is 
considered experimental/investigational. 
 
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 prostate artery embolization services. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found prostatic arterial embolization (PAE) is considered an experimental 
technique to treat symptomatic benign prostatic hyperplasia. Very limited studies have demonstrated possible 
short-term safety and efficacy of this service. The most recent American Urological Association guidelines do 
not recommend this procedure outside of a clinical trial setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of prostate artery embolization services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve prostate artery embolization services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve fabricated abutment on tooth #12 (D6057), abutment 
supported crown on tooth #12 (D6058), and sales tax (D9985). 
 
You asked the Plan to pre-approve abutment, crown, and sales tax. You say that these services are medically 
necessary. The Plan denied your request. The Plan says fabricated abutment (D6057), abutment supported 
crown (D6058), and sales tax (D9985) 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 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 
fabricated abutment on tooth #12 (D6057), abutment supported crown on tooth #12 (D6058), and sales tax 
(D9985).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve podiatry services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve podiatry services to be provided by an OON provider. You say that the 
services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able 
to provide these services. Therefore, coverage criteria have not been met. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the 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 
podiatry services to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this procedure is medically reasonable 
and necessary. The Plan denied your request. The Plan says the requested procedure is considered 
experimental/investigational. 
 
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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept procedure is experimental. More research is needed before coverage can 
be approved. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve BRCA testing. 
 
You asked the Plan to pre-approve BRCA testing. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that BRCA1 and BRCA2 testing is covered under specific 
circumstances. 
 
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 BRCA testing. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found BRCA1/BRCA2 genetic testing is non-
covered, for individuals with no personal history of breast, ovarian, fallopian tube, primary peritoneal, 
pancreatic, or prostate cancer. Such testing is considered screening and is excluded by Medicare statute. The 
review indicates that you do not meet the coverage criteria detailed in the 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 BRCA testing have not been met. Therefore, we decided that the Plan does not 
have to pre-approve BRCA testing.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation on March 15, 2022. 
 
You asked the Plan to pay for a periodic oral evaluation. You say that you were unaware the provider was 
OON. The Plan denied your request. The Plan says per the members 2022 Evidence of Coverage which states 
if the dentist you select is not in-network services are not covered, and no payment will be made. 
 
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 only 
covered under this benefit if they are received in-network. Therefore, we decided that the Plan does not have to 
pay for a periodic oral evaluation on March 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implants on tooth# 22 and 27 (D6010). 
 
You asked the Plan to pre-approve implants. You say that the implants are needed to support dentures. The 
Plan denied your request. The Plan says implants (D6010) are not covered by your 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 
implants on tooth# 22 and 27 (D6010).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341 x4) and 
gingival irrigation (D4921 x4) to be provided by a network provider. 
 
You asked the Plan to pre-approve the periodontal scaling and root planing (D4341 x4) and the gingival 
irrigation (4921 x4). You say that that root planing needs to be done due to periodontal disease. You say you do 
not have $840 to pay because you are on a fixed income. The Plan denied your request. The Plan says the 
services are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the periodontal scaling and root 
planing (D4341 x4) and gingival irrigation (D4921 x4) are not among those covered under this benefit. 
Therefore, we decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341 
x4) and gingival irrigation (D4921 x4) to be provided by a network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implant supported crown on tooth #2, 3, 4, 5, 13, 18, 19, 
20, 21, 23, 24, 29, 30, and 31 (D6065). 
 
You asked the Plan to pre-approve crowns. You say that you disagree with the denial for dental services. The 
Plan denied your request. The Plan says implant supported crowns (D6065) are not covered by your 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 
implant supported crown on tooth #2, 3, 4, 5, 13, 18, 19, 20, 21, 23, 24, 29, 30, and 31 (D6065).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sinus augmentation (D7951), guided tissue regeneration 
on tooth #14 and 15 (D4266), and abutment support crown on tooth #14 and 15 (D6059). 
 
You asked the Plan to pre-approve augmentation, tissue regeneration, and crowns. You say that these services 
are medically necessary. The Plan denied your request. The Plan says sinus augmentation (D7951), guided 
tissue regeneration (D4266), and abutment support crown (D6059) are not covered by your 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 sinus 
augmentation (D7951), guided tissue regeneration on tooth #14 and 15 (D4266), and abutment support crown 
on tooth #14 and 15 (D6059).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing the denied admission to IRF due to 
medical necessity. The Plan denied your request. The Plan says the enrollee does not have issues which needs 
the supervision of a rehabilitation physician. The enrollee does not meet all the required Medicare criteria for 
admission to an IRF and Skilled therapies at a skilled nursing facility may be approved. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found based on the documentation provided, it is their opinion that the health plans denial 
should be upheld. The enrollee does not require the intensity of services provided at an IRF. Specifically, the 
enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician 
evaluation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sclerotherapy services (36466). 
 
You asked the Plan to pre-approve sclerotherapy services. You say that this therapeutic service is medically 
necessary for the enrollee's condition. The Plan denied your request. The Plan says the Medicare criteria for 
coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that sclerotherapy is not considered medically 
necessary for vessels larger than 4 mm in diameter. 
 
We looked at the file and Medicare rules. In this case, the documentation clearly states that the enrollees 
vessels are larger than 4 mm in diameter. Based on this information, we decided that Medicare rules for 
coverage of sclerotherapy services have not been met. Therefore, we decided that the Plan does not have to pre-
approve sclerotherapy services (36466).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for targeted genomic sequence analysis (81455) provided 
January 7, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that this test was ordered by the treating 
physician because the test results were needed to help determine the course of treatment for this enrollee. 
Please find supporting documentation and evidence to support medical necessity. The Plan denied your request. 
The Plan says this testing is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.   
We looked at the file, and Medicare rules. The next generation sequence testing (NGS) testing panel performed 
included testing for the FANCC gene. Testing for this gene is not a Medicare benefit and is statutorily excluded 
service. In addition to single gene testing, panels that include the FANCC gene are statutorily excluded service. 
Based on this information, we decided that Medicare rules for coverage of the laboratory services have not 
been met. Therefore, we decided that the Plan does not have to pay for targeted genomic sequence analysis 
(81455) provided January 7, 2022.