Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit provided on July 12, 2022. 
 
You asked the Plan to waive the copayment for the office visit. You say that your doctor was very rude, and 
you want your $25 copayment back. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25 
copayment for an office visit with a specialist.  
 
You have been asked to pay a $25 copayment for an office visit with a specialist. This item/service falls within 
the Physician/Practitioner Services, Including Doctors Office Visits benefit category. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for the office visit provided on July 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit and debridement services (11720, 99347) 
provided on January 24, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the home visit and debridement services. 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 were non-emergent and prior authorization was not obtained. 
 
  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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a home visit and debridement services (11720, 
99347) provided on January 24, 2022 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone marrow aspirate (20939). 
 
You asked the Plan to pre-approve a bone marrow aspirate. You say that the requested bone marrow aspirate is 
medically necessary. The Plan denied your request. The Plan says the requested bone marrow aspirate is not 
medically necessary. 
 
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 a bone marrow aspirate. Our reviewer 
says that the requested bone marrow aspirate is not medically necessary. Our physician reviewer found the 
enrollee was being treated for spinal stenosis of the lumbar region. She presented with worsening pain of low 
back pain that radiates into the posterior aspect of both thighs. The pain is severe, and she can barely walk or 
stand for a long period. The pain is rated at 9/10. The exam reveals intact strength, sensation, and reflexes. The health plan approved the inpatient L3-4 decompression and fusion, and she has previously been approved for 
L4-5 decompression and fusion. 
 
However, there is no specific indication provided to support the request for bone marrow aspirate for the 
approved surgery. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use 
of bone marrow aspirate for this enrollees medical condition as discussed above. There is no compelling 
rationale presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception. Therefore, the requested bone marrow aspirate, in this case, 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 a bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a bone marrow aspirate (20939).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve deep gum and root cleaning in the lower left, lower 
right, and upper right quadrants (D4341) and periodontal scaling and root planing in the upper left quadrant 
(D4342). 
 
You asked the Plan to pre-approve the dental services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says deep gum and root cleaning (D4341) and periodontal scaling and root 
planing (D4342) 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 deep 
gum and root cleaning in the lower left, lower right, and upper right quadrants (D4341) and periodontal scaling 
and root planing in the upper left quadrant (D4342).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an onlay (D2664). 
 
You asked the Plan to pre-approve an onlay. You say that the Plan covers onlays, but only those made out of 
porcelain/ceramic. You also say that you would like this onlay to be covered. The Plan denied your request. 
The Plan says this service is not covered under your plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
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 an 
onlay (D2664).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wheelchair accessories. You asked the Plan to pre-approve the requested items. The Plan denied your request. The Plan says the 
enrollee can control power options using their own switches. 
 
The Plan follows Medicare rules. Medicare rules say that wheelchair options and accessories are only covered 
under certain medical indications. 
 
The file shows that an expandable control system was requested. 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 items. Our physician reviewer found that the enrollee was approved for a 
group 3 power wheelchair with tilt and recline, power elevating leg rests. the patient is independent in feeding 
and grooming. An evaluation showed the left upper extremity strength was noted as 3-/5 and left lower 
extremity strength was 2+/5. The enrollees upper extremity strength and function support that she can control 
any power options through their own switches. 
 
The file shows that a transit option was requested. An accessory that is beneficial primarily in allowing leisure 
or recreational activities is non-covered. An attendant control was also requested. An attendant control is non-
covered if it is in addition to beneficiary-operated drive control system. 
 
We looked at the physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested items have not been met. Therefore, we decided that the Plan does 
not have to pre-approve wheelchair accessories.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a partial 
mandibular denture (D5214). 
 
You asked the Plan to pre-approve the dental services. You say that your dentures were broken in a car 
accident. The Plan denied your request. The Plan says your benefit for the requested items or services 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 items or services was exhausted on date of service February 6, 2019. 
Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a 
partial mandibular denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown on tooth #14 (D2740). 
 
You asked the Plan to pre-approve a crown. You say that the tooth is causing you a lot of pain. The Plan denied 
your request. The Plan says the tooth does not appear to have a significant breakdown due to decay or trauma. 
 
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 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. Our reviewer says that the 
coverage criteria has not been met. Our physician reviewer found that there is only an existing single surface 
restoration and no clearly involved additional surfaces. If a restoration is needed it would be reasonably 
restored with a conventional restoration which would provide a good prognosis. A crown would not be 
indicated in this situation due to a lack of compromised structure. 
 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 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a crown on tooth #14 (D2740).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a complete 
mandibular denture (D5120). 
 
You asked the Plan to pre-approve the complete dentures. You say that your current dentures do not fit 
properly, and you cannot eat with them. 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 January 8, 2020. 
Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a 
complete mandibular denture (D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-precision attachment, placement (D6192). 
 
You asked the Plan to pre-approve the dental service. You say that you need this service in order for your 
denture to be replaced. 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 pre-approve a 
semi-precision attachment, placement (D6192).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete denture (D5120). 
 
You asked the Plan to pre-approve the dental services. You say that a new denture is medically necessary. 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 28, 2021. Therefore, 
we decided that the Plan does not have to pre-approve a complete denture (D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2750) for tooth #8. 
 
You asked the Plan to pre-approve a crown (D2750) for tooth #8. The Plan denied your request. The Plan says 
the tooth does not appear to have significant breakdown due to decay or trauma. The Plan also says the x-rays 
provided show a crown is not needed to fix your tooth. 
 
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 
(D2750) for tooth #8 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 (D2750) for tooth #8. Our 
reviewer says that a crown (D2750) for tooth #8 is not considered reasonable and necessary at this time. Our 
physician reviewer found the provided x-ray shows a restored tooth #8 with an existing restoration and occlusal 
wear. The amount of missing structure is about 35% of the total coronal structure with about 40% of the incisal 
structure being involved, mostly due to the attrition of that edge. Our reviewer found that the Plan requires that 
for anterior crowns that four or more surfaces be involved and at least 50% of the incisal edge. Our physician 
reviewer also found that given the limited amount of involved structure of tooth #8, it would not be considered 
necessary to place a crown on tooth #8. 
 
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 (D2750) for tooth #8 have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a crown (D2750) for tooth #8.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cone beam computed tomography (CT) capture and 
interpretation (D0367) and five placements of intra-socket biological dressings (D7922 x5). 
 
You asked the Plan to pre-approve a cone beam CT capture and interpretation and placements of intra-socket 
biological dressings. You say that the CT scan was requested because your tooth may be extending into your 
sinus cavity. 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 
cone beam computed tomography (CT) capture and interpretation (D0367) and five placements of intra-socket 
biological dressings (D7922 x5).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete mandibular denture (D5120). 
 
You asked the Plan to pre-approve a complete denture. You say that you need a new pair of dentures. The Plan 
denied your request. The Plan says a complete mandibular denture (D5120) 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 a 
complete mandibular denture (D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of torus palatinus (D7472), deep sedation 
(D9222, D9223), and therapeutic parenteral drugs (D9612). 
 
You asked the Plan to pre-approve the dental services. You say that you disagree with denial of dental services. 
The Plan denied your request. The Plan says that the removal of torus palatinus (D7472), deep sedation 
(D9222, D9223), and therapeutic parenteral drugs (D9612) 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 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 the 
removal of torus palatinus (D7472), deep sedation (D9222, D9223), and therapeutic parenteral drugs (D9612).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213) and three 
extractions (D7140 x3). 
 
You asked the Plan to pre-approve a maxillary partial denture and extractions. You say that you need these 
services provided because you cannot eat with only three teeth remaining. You also say that you cannot afford 
to pay for these services on your own. The Plan denied your request. The Plan says these services are not 
covered under your plan. The Plan also says that you are not enrolled in a dental rider. 
 
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 
maxillary partial denture (D5213) and three extractions (D7140 x3).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of an impacted tooth (D7230), drugs 
dispensed for home use (D9630), and therapeutic parenteral drug (D9610), provided by a participating 
provider. 
 
You asked the Plan to pre-approve the removal of an impacted tooth, drugs dispensed for home use, and 
therapeutic parenteral drug. You say that these services are medically necessary. The Plan denied your request. 
The Plan says the requested 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 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 the removal of an impacted tooth (D7230), drugs dispensed for home use (D9630), and therapeutic parenteral drug 
(D9610), provided by a participating provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the knee arthroscopy (CPT code 29870).

You asked the Plan to pre-approve the knee arthroscopy. You say that you need surgery because you cannot
walk or sleep at night, without surgery you may never be able to walk unassisted again. The Plan denied your
request. The Plan says the service is not necessary.

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 knee arthroscopy. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found there is no compelling rationale presented or extenuating circumstances noted to
support the medical necessity of this request as an exception to guidelines. Therefore, the requested a right knee
arthroscopy (CPT 29870), in this case, 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 knee arthroscopy have not been met. Therefore, we decided that the Plan
does not have to pre-approve the knee arthroscopy (CPT code 29870).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the advanced foot with ankle and knee feature for a 
prosthesis. 
 You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that prosthetic accessories 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records do not support that the 
enrollee participates in high intensity activity that requires a vertical shock reducing feature. The 
documentation does not support that the enrollee functions at the K3 level. The request exceeds the enrollee's 
functional needs and is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the advanced foot with ankle and knee feature for a prosthesis.