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

 
We decided that the Plan does not have to pre-approve retainer crowns (D6750) for teeth # 13 and 25, and a 
pontic (D6240) for tooth # 14. 
 
You asked the Plan to pre-approve a fixed bridge. You say that you are not able to chew. You also say that 
your provider is not able to fix the original bridge. The Plan denied your request. The Plan says the requested 
bridge is not medically necessary. 
 
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 and fixed bridges are listed as covered, they are not covered when needed to replace a posterior tooth. The record shows that the requested bridge is for 
the replacement of tooth # 14, a posterior tooth. Therefore, we decided that the Plan does not have to pre-
approve retainer crowns (D6750) for teeth # 13 and 25, and a pontic (D6240) for tooth # 14.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel provided on February 21, 2021. 
 
You asked the Plan to pay for the testing services. You say that the gene panel detects genomic alterations. The 
Plan denied your request. The Plan says one code must be submitted for the panel. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The gene panel at issue was billed with multiple codes. If a single procedure is performed, only one code with 
one unit of service may be reported for the procedure. Based on this information, we decided that Medicare 
rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have 
to pay for the gene panel provided on February 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the implant supported denture (D6111), connecting bar 
(D6055), and custom fabricated abutments (D6057 x 3) provided on October 27, 2021. 
 
You asked the Plan to pay for the dental services. You say that your dentures needed to be replaced. You say 
that the upper denture was paid but the lower denture was not. You say that your coverage information does not 
indicate that the denture you need is not covered. You also say that this should be covered in full. The Plan 
denied your request. The Plan says the services you received are not listed as covered dental 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 implant supported denture, 
connecting bar, and custom fabricated abutments are not among those covered under this benefit. Therefore, we 
decided that the Plan does not have to pay for the implant supported denture (D6111), connecting bar (D6055), 
and custom fabricated abutments (D6057 x 3) provided on October 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for the crown (D2752) provided on 
January 4, 2022. 
 
You asked the Plan to pay an additional amount for the dental service. You say that you needed this crown after 
you had a root canal. You say that you need to have this crown to avoid losing the tooth. You also say that you 
cannot afford to lose any teeth on your right side. The Plan denied your request. The Plan says the porcelain 
crown paid at the least costly method of treatment as a metal crown. The Plan also says that you are responsible 
for the difference between the allowed amounts plus the 50% coinsurance. 
 
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 and crowns are listed as covered, the 
service was paid based on the least costly method of treatment, per the Evidence of Coverage. Additionally, the 
remaining balance is your responsibility. Therefore, we decided that the Plan does not have to pay an additional 
amount for the crown (D2752) provided on January 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crowns (D2740) for tooth #'s 12 and 13. 
 
You asked the Plan to pre-approve the crowns. The Plan denied your request. The Plan says this service is not 
covered under your plan. The Plan also says that you were not enrolled in an optional supplemental dental plan 
during the 2021 plan year, nor are you enrolled in an optional supplemental dental plan for the 2022 plan year. 
 
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 
crowns (D2740) for tooth #'s 12 and 13.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental implant (D6010), bone replacement graft 
(D7953), custom-fabricated abutment (D6057) and implant-supported crown (D6066) for tooth #5. 
 
You asked the Plan to pre-approve implant services for tooth #5. You say that these services are necessary. The 
Plan denied your request. The Plan says these services are 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 pre-approve a 
dental implant (D6010), bone replacement graft (D7953), custom-fabricated abutment (D6057) and implant-
supported crown (D6066) for tooth #5.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the resin-based composite (D2392) on tooth #3 
provided on January 19, 2022. 
 
You asked the Plan to pay more for the resin-based composite. You say that you already paid $52.50 for this 
service and thought the remainder would be covered by your insurance. The Plan denied your request. The Plan 
says benefits have been paid on the least costly method of treatment, and you will be responsible for the 
remaining balance. The Plan also says that when there are multiple, clinically acceptable treatment options, the 
Plan will pay for the least expensive treatment option. 
 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, white fillings on posterior teeth are 
processed as a silver filling and you are responsible for up to the contracted fee. The record shows that you 
received a resin-based composite (white filling) on tooth #3, which is a posterior tooth. Therefore, we decided 
that the Plan does not have to pay more for the resin-based composite (D2392) on tooth #3 provided on January 
19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete mandibular denture (D5120) provided by a 
participating provider. 
 
You asked the Plan to pre-approve a complete mandibular denture. You say that you would like the Plan to 
approve these services. The Plan denied your request. The Plan says the requested 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. 
 
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 mandibular denture (D5120) provided by a participating provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cardiac rhythm monitor for the enrollee. 
 
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no clinical information documenting medical necessity. 
 
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 monitor. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the patient had no history of atrial fibrillation, nor were any significant cardiac arrhythmias noted on 
ECG monitoring. A recent randomized clinical trial found that continuous monitoring for atrial fibrillation with 
an implantable loop recorder (ILR) (followed by treatment with oral anticoagulation if atrial fibrillation was 
detected) was not superior to usual care in reducing stroke or systemic embolism among patients at high risk of 
stroke but without a known prior history of atrial fibrillation). At this time, insertion of an ILR would not be 
considered medically appropriate and necessary in this patients clinical management. 
 
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 monitor have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a cardiac rhythm monitor for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 extractions (D7140) and scaling and root planing 
(D4341) for all 4 quadrants. 
 
You asked the Plan to pre-approve the dental services. You say that you have had a toothache for over a month. 
You say that you went to get your tooth pulled. You say that you were advised it was not covered. You also say 
that you would like this to be covered or you will need to change your insurance. The Plan denied your request. 
The Plan says extractions and scaling and root planing are not listed as 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 extractions and scaling 
and root planing are not among those covered under this benefit. Therefore, we decided that the Plan does not 
have to pre-approve 8 extractions (D7140) and scaling and root planing (D4341) for all 4 quadrants.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a K3 prosthetic leg and components described by codes 
L5828, L5845, L5848 and L5856. 
 
You asked the Plan to pre-approve the requested prosthetic components. You say that all requested components 
are medically necessary. The Plan denied your request. The Plan says the requested prosthetic components 
exceed your needs. 
 
The Plan follows Medicare rules. Medicare rules say that certain prosthetic components are only covered when 
the enrollee is at a specific functional level.  
 
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 prosthetic components. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found the documentation 
is not clear in the physician progress notes that you require a microprocessor K3 knee over a mechanical knee. 
Your prior level of function was a walker and current level is a manual wheelchair. The physicians note on 
5/11/22 states that currently you are a K2 ambulator and have potential to be a K3 ambulator. The 
documentation is not clear that you are a K3 ambulator that requires a microprocessor knee. 
 
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 prosthetic components have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a K3 prosthetic leg and components described by codes L5828, 
L5845, L5848 and L5856.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you need LTACH care. The Plan denied 
your request. The Plan says you are receiving appropriate in-patient acute care and do not require transfer to an 
LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where he is currently receiving care. All medically necessary care is being provided in the 
current acute care facility. The health plan has approved ongoing care in the current acute care facility. The 
requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical implant placements (D6010), custom-fabricated 
abutments (D6057) and bone replacement grafts (D7953) for teeth #22 and #27, and an implant/abutment 
supported fixed denture for a toothless lower arch (D6115). 
 
You asked the Plan to pre-approve dental/implant services. You say that these services are necessary due to 
other medical conditions. The Plan denied your request. The Plan says these services are 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 pre-approve 
surgical implant placements (D6010), custom-fabricated abutments (D6057) and bone replacement grafts 
(D7953) for teeth #22 and #27, and an implant/abutment supported fixed denture for a toothless lower arch 
(D6115).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical removal of implant body (D6100) provided 
September 27, 2021. 
 
You asked the Plan to pay for the surgical implant removal. You say that you would like this to be covered. 
The Plan denied your request. The Plan says this service is not covered under your 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 the 
surgical removal of implant body (D6100) provided September 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the special anesthesia service (99100) provided on July 20, 2021.  

You asked the Plan to pay for the special anesthesia service (99100). The Plan denied your request. The Plan 
says procedure code 00813 has been overturned and procedure code 99100 remains denied as bundled services 
are not eligible for separate payment. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99100 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the special anesthesia service (99100) have not been met. Therefore, we decided that the Plan does not have 
to pay for the special anesthesia service (99100) provided on July 20, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve four (4) additional home physical therapy (PT) visits 
(G0151). 
 
You asked the Plan to pre-approve additional home PT visits. You say that the requested additional home PT 
visits are medically necessary. The Plan denied your request. The Plan says the requested additional home PT 
visits do not meet requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve additional home PT visits. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found the additional requested therapy generally is not accepted as 
specific and effective therapy for your condition beyond what was approved by the health plan. You have had 
prior therapy and the documentation does not reveal that you require the unique skills of a professional 
therapist to provide treatment safely and effectively, that the services can be safely and effectively performed 
only by a therapist, or by or under the supervision of a therapist. You have been instructed in a home exercise 
program. The requested services are not part of a maintenance program, and the specialized skill, knowledge 
and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain 
your current condition or to prevent or slow further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional home PT visits have not been met. Therefore, we decided that the 
Plan does not have to pre-approve four (4) additional home physical therapy (PT) visits (G0151).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller identified with code E2377, 
electronic connection between wheelchair controller and two or more power seating system motors identified 
with code E2311, and the harness for upgrade to expandable controller identified with code E2313. 
 
You asked the Plan to pre-approve an expandable controller, electronic connection between wheelchair 
controller and two or more power seating system motors, and the harness for upgrade to expandable controller. 
You say that you require these items to meet mobility needs. The Plan denied your request. The Plan says the 
requested items are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that power wheelchair accessories are only covered 
for certain indications.  
 
We looked at the file and Medicare rules. Review of the file shows that although there are three approved 
power options/features on the wheelchair, the documentation does not support a medical need to control these 
power options/features through the joystick. Based on this information, we decided that Medicare rules for 
coverage of an expandable controller, electronic connection between wheelchair controller and two or more 
power seating system motors, and the harness for upgrade to expandable controller have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an expandable controller identified with code 
E2377, electronic connection between wheelchair controller and two or more power seating system motors 
identified with code E2311, and the harness for upgrade to expandable controller identified with code E2313.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neuroablation. 
 
You asked the Plan to pre-approve neuroablation. 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 Facet Joint Interventions are covered when specific 
criteria are met. 
 
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 neuroablation. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records do not show that the 
enrollee has completed the 2 required injections required to confirm where the pain is coming from first. 
Medical studies do not show that this procedure works as well when that is the case. In addition, the medical 
records show that the enrollee had another health issue (osteomyelitis) that could be causing his back pain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of neuroablation have not been met. Therefore, we decided that the Plan does not 
have to pre-approve neuroablation.