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

 
We decided that the Plan does not have to pre-approve a crown - porcelain/ceramic tooth #19 (D2740). 
 
You asked the Plan to pre-approve a crown - porcelain/ceramic tooth #19 (D2740). The Plan denied your 
request. The Plan says crowns are not covered for cosmetic reasons or for closing gaps. 
 
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 a crown - 
porcelain/ceramic (D2740) 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 - porcelain/ceramic tooth #19 
(D2740). Our reviewer says that the requested crown on tooth #19 would not be considered medically 
necessary. Our physician reviewer found the request for a crown on #19 in order to close the space between #'s 
18 and 19.  There is an existing restoration and noted distal caries on #19 but it involves less that fifty percent of the total 
coronal structure. The Plan specifically does not cover crowns for the purpose of closing spaces between teeth 
and allows for crowns where there is extensive structural breakdown. As the damage to the tooth is less than 
fifty percent the Plan criteria for crowns would not be met, and also for the purposes of closing a space between 
two teeth. 
 
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 - porcelain/ceramic tooth #19 (D2740) have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a crown - porcelain/ceramic tooth #19 (D2740).
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pre-approve sleep study in sleep lab with continuous airway pressure (CPT) code 95811).

You asked the Plan to pre-approve the sleep study. You say that the service is necessary. The Plan denied your request. The Plan says that your request is not medically necessary because the enrollee has a recent valid sleep study with a long-established diagnosis of obstructive sleep apnea. The Plan states further studies are not needed for re-implementation of continuous positive airway pressure (CPAP) use or treatment management.

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 sleep study. Our physician reviewer found the provided records in this case indicate repeat testing is needed for "confirmation of the efficacy of prescribed therapy" i.e., confirming the correct CPAP mask fit. 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 sleep study have been met. Therefore, we decided that the Plan has to pre-approve sleep study in sleep lab with continuous airway pressure (CPT) code 95811). 

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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mastectomy procedure.

You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the
enrollee does not meet the coverage criteria.

The Plan follows Medicare rules. Medicare rules say that reconstructive surgery is only covered under certain
medical indications.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician
reviewer found that the enrollee has gynecomastia. The record provided does not document that reversible
causes of gynecomastia have been ruled out. The record does not document that an endocrine evaluation has
been performed. The record provided is insufficient to establish the medical necessity and reasonableness, as
defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. The
requested service is not 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 the requested services have not been met. Therefore, we decided that the Plan
does not have to pre-approve a mastectomy procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Life2000 ventilator.

You asked the Plan to pre-approve the requested services. You say that the ventilator does not have bi-level settings. The Plan denied your request. The Plan says a BiPAP will meet the enrollee's needs.

The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD.

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 COPD, asthma, and was recently hospitalized with Covid-19. The arterial blood gas (ABG) was consistent with acute-on-chronic hypercarbic respiratory failure. The enrollee already has a Trilogy ventilator at home. The Life2000 is not a true ventilator because it is not capable of providing full ventilatory support. There is inadequate evidence that it is beneficial in the treatment of COPD or asthma. The Life2000 system 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 the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Life2000 ventilator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.

You asked the Plan to pre-approve IRF care. You say that the services requested are medically necessary. The
Plan denied your request. The Plan says the inpatient rehabilitation facility (IRF) services you are requesting do
not meet the requirements for approval.

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 clinical documentation shows that patient has functional impairments and active
hospital complications but there are no complex deficits that would warrant intense therapy or interdisciplinary
team management. There is no EMG/NCS that confirms diagnosis of steroid induced myopathy thus no IRF
compliant diagnosis. IRF criteria not met.

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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the office visits (99203 x 2, 99213), and infrared 
therapy (97026 x 5) provided from January 6, 2022, to April 19, 2022. 
 
You asked the Plan to reimburse you for the office visits and infrared therapy. You say that you have paid the 
full amount for these services. You say that it has helped you. You also say that you need to go back. The Plan 
denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. The Plan documents 
specifically indicate that services other than manipulation, when performed by a chiropractor, are not covered. Additionally, infrared therapy is not covered by Medicare. Therefore, we decided that the Plan does not have to 
reimburse you for the office visits (99203 x 2, 99213), and infrared therapy (97026 x 5) provided from January 
6, 2022, to April 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gingival flap procedures (D4240) provided on June 7, 2022. 
 
You asked the Plan to pay for the procedures. You say that you disagree with the denial of dental services. The 
Plan denied your request. The Plan says gingival flap procedures (D4240) 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 pay for gingival 
flap procedures (D4240) provided on June 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) and core buildup (D2950) for tooth 
#8. 
 
You asked the Plan to pre-approve a crown and core buildup. You say that the enrollee is slowly losing more of 
their teeth and only has a few remaining. The Plan denied your request. The Plan says the enrollee does not 
meet the criteria for coverage of a crown and core buildup. 
 
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 a crown and 
core buildup 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 core buildup. Our reviewer 
says that the documentation provided does not meet the criteria for coverage for core buildup and crown for 
tooth #8. Our physician reviewer found that tooth #8 appears significantly broken down and non-restorable. 
Tooth #8 has inadequate bone support and a poor prognosis for retention and as abutments for a prosthesis. 
 
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 core buildup have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a crown (D2740) and core buildup (D2950) for tooth #8.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown restoration (D2751) for tooth #30 provided by a 
participating provider. 
 
You asked the Plan to pre-approve a crown restoration. You say that you need this dental work. The Plan 
denied your request. The Plan says this dental work 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. The Plan covers a crown 
restoration 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 restoration. Our physician 
reviewer found the documentation provided does not meet the criteria for a crown restoration for tooth #30. 
 
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 restoration have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a crown restoration (D2751) for tooth #30 provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral - complete series of radiographic images (D0210) 
provided on April 26, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told by a plan representative there was 
no dental history at all specifically for the requested procedure. 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. Intraoral - complete series of 
radiographic images (D0210) but is limited to one procedure code every 5 calendar years. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested intraoral - complete series of radiographic images (D0210) was exhausted 
on date of service August 26, 2019. Therefore, we decided that the Plan does not have to pay for intraoral - 
complete series of radiographic images (D0210) provided on April 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crown porcelain/ceramic tooth #6 and #10 (D2740). 
 
You asked the Plan to pre-approve dental services. You say that the crowns were not done properly and is 
causing issues. The Plan denied your request. The Plan says the x-rays do not show the tooth to have decay or 
loss due to fracture involving more than 50% of the incisal edge of the tooth or tooth surfaces. Also, they say 
this service is only allowed one time every 7 years. 
 
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 dental 
services when the services are medically necessary and reasonable.  
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve dental services. Our physician reviewer 
found if they were improperly placed and non-functional in the occlusion, they could be considered for 
replacement when the 84-month waiting period is expired based on non-functional occlusion or defective 
margins if applicable.  At the present time there is no necessity for replacement under the Plan as the existing 
crowns are intact and not within the scope of coverage due to waiting period. 
 
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 dental services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve crown porcelain/ceramic tooth #6 and #10 (D2740).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a chair for a seat lift mechanism.

You asked the Plan to pre-approve these services. You say that you would like the plan to pay for the whole
mechanism. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we
decided that the Plan does not have to pre-approve a chair for a seat lift mechanism.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for two porcelain/ceramic crowns (D2740) of teeth #8 and #9 
provided on April 14, 2022. 
 
You asked the Plan to pay for the dental services. You say that you had a fall which broke your two upper front 
teeth. You say the services were a direct result of trauma from the fall and should be covered. The Plan denied 
your request. The Plan says the claim was processed correctly. There is no coverage for D2740, and the Plan 
says that there was no effort to obtain a prior authorization 
 
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 two 
porcelain/ceramic crowns (D2740) of teeth #8 and #9 provided by, on April 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on July 
22, 2022. 
 
You asked the Plan to pay for the dental services. You say that you feel the service should be covered because 
you are allowed two cleanings per year. The Plan denied your request. The Plan says your benefit for the 
requested item or service has already been exhausted. The record shows you received a comprehensive oral 
exam. A cleaning is a separate service and does not apply in this case. 
 
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 January 14, 2020. This 
means you would not be eligible to receive another comprehensive oral exam until 2023. Therefore, we 
decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on July 22, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
May 11, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service May 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on July 12, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration for 
payment. 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 May 23, 2022. Therefore, 
we decided that the Plan does not have to pay for the dental services on July 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup services and a crown (D2740, D2950) provided 
on June 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your dental benefit maximum allowance of $1,000 
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 June 22, 2022. Therefore, 
we decided that the Plan does not have to pay for core buildup services and a crown (D2740, D2950) provided 
on June 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date of service 
June 7, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary. The Plan denied 
your request. The Plan says the code is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. We looked at the file and Medicare rules. We find that the testing described by code 83789 is not separately 
payable. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, 
we decided that the Plan does not have to pay for validity testing billed with code 83789 for date of service 
June 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing (D4342) provided on 
October 14, 2021. 
 
You asked the Plan to pay for the periodontal scaling and root planing. You say that the services should be 
covered as you disagree with the denial The Plan denied your request. The Plan says the services denied 
correctly as they do not fall within 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 pay for 
periodontal scaling and root planing (D4342) provided on October 14, 2021.