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

 
We decided that the Plan does not have to pre-approve surgical placement of implant body: endosteal implant 
(D6010), custom fabricated abutment  includes placement (D6057) and abutment supported porcelain fused to 
metal crown (high noble metal) (D6059). 
 
You asked the Plan to pre-approve an endosteal implant, custom fabricated abutment and abutment supported 
crown. You say that these services are necessary, and you were told you could use your $200 dental allowance. 
The Plan denied your request. The Plan says these services are 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 pre-approve surgical placement of implant body: endosteal implant (D6010), custom fabricated abutment  includes 
placement (D6057) and abutment supported porcelain fused to metal crown (high noble metal) (D6059).  
 
Your complaint about potentially being provided misinformation is not a valid appeal for medical coverage. 
This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to 
make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gingival irrigation (D4921). 
 
You asked the Plan to pre-approve the dental service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says gingival irrigation is not listed as a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested gingival irrigation is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
gingival irrigation (D4921).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for respiratory pathogen panel testing provided on October 18, 
2021.  
You asked the Plan to pay for respiratory pathogen panel testing. You say that respiratory pathogen panel 
testing was a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that panels with greater than 5 respiratory pathogens 
are not medically reasonable and necessary.  
 
We looked at the file and Medicare rules. In this case, the record shows that the enrollee was provided with 
respiratory pathogen panel testing for greater than 5 respiratory pathogens. Based on this information, we 
decided that Medicare rules for coverage of respiratory pathogen panel testing have not been met. Therefore, 
we decided that the Plan does not have to pay for respiratory pathogen panel testing provided on October 18, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone replacement grafts on tooth #5, 16, 22, and 30 
(D4264). 
 
You asked the Plan to pre-approve the dental services. You say that you disagree with the denial of dental 
services. 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 the Plan pre-approved bone replacement grafts already in these quadrants, therefore your benefit for this 
service has been exhausted. We decided that the Plan does not have to pre-approve bone replacement grafts on 
tooth #5, 16, 22, and 30 (D4264).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99072 billed for date of service February 21, 
2022. 
 
You asked the Plan to pay for procedure code 99072. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says procedure code 99072 is considered 
bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code.  
We find that procedure code 99072 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99072 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99072 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99072 billed for date of service February 21, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient hospital services for the enrollee. 
 
You asked the Plan to pre-approve inpatient hospital services. You say that these services are medically 
necessary. The Plan denied your request. The Plan says that there is no documentation provided to support the 
expectation the enrollee will require a greater than 2 midnight stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 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 inpatient hospital services. Our 
reviewer says that inpatient hospital services are not medically reasonable and necessary. The provided 
documentation shows the patient was cleared for surgery without any unstable conditions or other factors that 
would predict high risk complications from this procedure. There is no indication that the patient would require 
hospital services that would likely cross 2 midnights related to this procedure. Our physician reviewer found 
that the enrollee's condition does not meet criteria for coverage of inpatient hospital services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient hospital services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient hospital services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown on tooth #7, 8, and 9 (D2750) and core build up 
on tooth #7, 8, and 9 (D2950). 
 
You asked the Plan to pre-approve crowns and core build up. You say that you disagree with the denial of 
dental services. The Plan denied your request. The Plan says crowns (D2750) and core build up (D2950) are 
not covered by your supplemental 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 
crown on tooth #7, 8, and 9 (D2750) and core build up on tooth #7, 8, and 9 (D2950).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110). 
 
You asked the Plan to pre-approve the dental services. You say that your dentures were stolen while in therapy. 
You say you would like a replacement for your health, eating properly, and for appearance. The Plan denied 
your request. The Plan says your benefit for a complete upper denture has already been exhausted. The Plan 
also notes that procedures performed solely for cosmetic and/or aesthetic reasons are excluded from the 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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service January 26, 2022. 
Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mandibular partial denture (D5214). 
 
You asked the Plan to pre-approve the dental services. You say that your dentures were misplaced while you 
were in the hospital. 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 July 23, 2019. Therefore, 
we decided that the Plan does not have to pre-approve a mandibular partial denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mandibular partial denture (D5212) and a maxillary 
partial denture (D5211). 
 
You asked the Plan to pre-approve partial dentures. You say that you need new dentures. The Plan denied your 
request. The Plan says a mandibular partial denture (D5212) and a maxillary partial denture (D5211) 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 a 
mandibular partial denture (D5212) and a maxillary partial denture (D5211).
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 with limited field of view  less than one whole jaw (D0364). 
 
You asked the Plan to pre-approve a cone beam CT scan. You say that this service is necessary. 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 pre-approve a 
cone beam computed tomography (CT) capture and interpretation with limited field of view  less than one 
whole jaw (D0364).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transfer handles for a power wheelchair. 
 
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 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. Therefore, we 
decided that the Plan does not have to pre-approve transfer handles for a power wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve maxillary partial denture - flexible base (D5225) and 
mandibular partial denture - flexible base (D5226). 
 
You asked the Plan to pre-approve the dental services. You say that you lost your dentures and you need them 
so you can eat well. 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 21, 2021. Therefore, 
we decided that the Plan does not have to pre-approve maxillary partial denture - flexible base (D5225) and 
mandibular partial denture - flexible base (D5226).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interim partial denture - maxillary (D5820). 
 
You asked the Plan to pre-approve the denture. You say that you are in pain and you are worried about an 
infection. The Plan denied your request. The Plan says this is not a covered service 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 an 
interim partial denture - maxillary (D5820).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services (D9310, D9223, D9222, D7140, D9310, 
D9223, D9222) to be provided by an out-of-network provider. 
 
You asked the Plan to pre-approve 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 dental services from an out-of-network 
provider are not covered by your supplemental 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. 
 
 
  You are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested items or services are not covered under this benefit when received 
from an out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve dental 
services (D9310, D9223, D9222, D7140, D9310, D9223, D9222) to be provided by an out-of-network 
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a set of complete upper and lower dentures (D5110, 
D5120). 
 
You asked the Plan to pre-approve the dental services. You say that you never used the partial dentures and you 
do not have them. You say you only have the temporary partial dentures and wish to reinstate your denture 
benefit. 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 April 4, 2022. This 
means you would not be eligible for the benefit until April 4, 2027. Therefore, we decided that the Plan does 
not have to pre-approve a set of complete upper and lower dentures (D5110, D5120).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the flex-walk system (L5981). 
 
You asked the Plan to pre-approve the flex-walk system. You say that this equipment is medically reasonable 
and necessary. The Plan denied your request. The Plan says the enrollee is not a K3 ambulator as required for 
coverage of the flex-walk system. 
 
The Plan follows Medicare rules. The rules say that a microprocessor-controlled ankle foot system (L5973), 
energy storing foot (L5976), dynamic response foot with multi-axial ankle (L5979), flex foot system (L5980), 
flex-walk system or equal (L5981), or shank foot system with vertical loading pylon (L5987) is covered for 
beneficiaries whose functional level is 3 or above. 
 
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 flex-walk system. Our reviewer 
says that the requested equipment is not medically reasonable and necessary. Our physician reviewer found that 
the enrollee has no continued evidence of vascular compromise on the right leg. They have good wound 
healing. In this case, the record provides no predictive evidence such as walk time or current functional status to identify the probability of the enrollee likely being a K3 ambulator. 
 
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 flex-walk system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the flex-walk system (L5981).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve buccal / labial frenectomy (D7961) and autogenous 
connective tissue graft (D4273). 
 
You asked the Plan to pre-approve the buccal frenectomy and tissue graft. You say that these procedures would 
prevent you from having to have a tooth extraction in the future. The Plan denied your request. The Plan says 
these services are not covered under your dental 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 
buccal / labial frenectomy (D7961) and autogenous connective tissue graft (D4273).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve i-Factor Allograft services. 
 
You asked the Plan to pre-approve i-Factor Allograft services. You say that the records provided support the 
need for the requested services. The Plan denied your request. The Plan says the clinical value and 
effectiveness of the i-Factor Allograft in the setting of transforaminal lumbar interbody fusion procedure has 
not been demonstrated in the peer-reviewed literature. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve i-Factor Allograft services. Our 
reviewer says that i-Factor Allograft services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this treatment is experimental. More research is needed. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of i-Factor Allograft services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve i-Factor Allograft services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve re-implantation and/or stabilization of an accidentally 
evulsed or displaced tooth on tooth #6, 7, 8, 9, 10, and 11 (D7270). 
 
You asked the Plan to pre-approve the dental services. You say that you fell and damaged your teeth. The Plan 
denied your request. The Plan says re-implantation and/or stabilization of an accidentally evulsed or displaced 
tooth (D7270) is 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 re-
implantation and/or stabilization of an accidentally evulsed or displaced tooth on tooth #6, 7, 8, 9, 10, and 11 
(D7270).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cone beam CT capture of both jaws (D0367) and a 
consultation for a diagnostic service (D9310). 
 
You asked the Plan to pre-approve the dental services. You say that you need the requested services to treat 
ongoing pain in your gums. You say you need bones removed so you can eat sufficiently. The Plan denied your 
request. The Plan says the services are not covered under your benefit package. 
 
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. The supplemental dental benefit clearly states that any services not 
included in the comprehensive list of covered dental procedures are thereby not covered. Therefore, we decided 
that the Plan does not have to pre-approve a cone beam computed tomography (CT) capture of both jaws 
(D0367) and a consultation for a diagnostic service (D9310).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive periodontal evaluation (D0180). 
 
You asked the Plan to pre-approve the evaluation. You say that you have a tooth that is causing you pain. The 
Plan denied your request. The Plan says this service is not a covered benefit 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 a 
comprehensive periodontal evaluation (D0180).