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

 
We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220) and additional 
intraoral periapical x-ray (D0230) provided on November 19, 2021. 
 
You asked the Plan to pay for the intraoral periapical x-rays. You say that you would like the $70 debited 
retroactively to your flex card. The Plan denied your request. The Plan says these services are not covered 
expenses under your dental plan. The Plan also says that during your call with the Plan, you were correctly 
advised of your benefits and network provider. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the first 
intraoral periapical x-ray (D0220) and additional intraoral periapical x-ray (D0230) provided on November 19, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genomic profile testing provided on September 8, 2021. 
 
You asked the Plan to pay for the testing services. You say that the results were needed to help determine 
treatment for the enrollee. The Plan denied your request. The Plan says the test is non-covered. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. The service at issue, billed with code 81455 is unlikely to impact 
therapeutic decision-making in the clinical management of the enrollee. 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 genomic profile testing provided on September 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for removal of torus mandibularis (dental code D7473) you 
received on September 13, 2021. 
 
You asked the Plan to pay for dental code D7473. You say that you were told that you just had to pay your 
portion for this service.  You said that you are on a fixed income. The Plan denied your request. The Plan says 
dental code D7473 is not on the covered dental services list. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Your Plan's dental benefit 
includes coverage only for those dental services explicitly listed in your dental benefits chart. Dental code 
D7473 is not listed in this chart as a covered dental service. 
 
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 removal 
of torus mandibularis (dental code D7473) you received on September 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two (2) office visits. 
 
You asked the Plan to pre-approve two (2) office visits. You say that you should receive coverage for these 
services as you are a diabetic, and your PCP advised you that you need these services due to abnormally dry 
skin. The Plan denied your request. The Plan says the notes show you are doing well with the current treatment, 
and you should return to your primary care doctor for follow up. The Plan has approved one visit. 
 
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 two (2) office visits with the provider. Our reviewer says that two office visits are not medically necessary. Our physician reviewer found this dermatologist has identified a treatment plan for self-maintenance of your dry skin care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of two (2) office visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve two (2) office visits.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 18 home health occupational therapy (OT) visits. 
 
You asked the Plan to pre-approve 18 home health OT visits. The Plan denied your request. The Plan says  
18 home health OT visits are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 18 home health OT visits. Our reviewer 
says that the OT visits are not medically necessary. Our physician reviewer found that your functional level 
does not require the skills of a professional therapist and you were trained in an independent home exercise 
program. Home health OT services are not medically necessary per Medicare Benefit Policy Manual,  
Chapter 7. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 18 home health OT visits have not been met. Therefore, we decided that the 
Plan does not have to pre-approve 18 home health OT visits.
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee can safely receive the services he needs at a less intensive 
setting. 
 
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.  The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. The patient has a past medical history of 
Parkinson's disease and chemotherapy related myopathy and is living at home with progressive weakness. The 
enrollees medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does 
not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the patient has a need for physical and/or occupational therapy, 
there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable 
expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet 
Medicare criteria for IRF care. 
 
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 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Rheo Knee (K3 microprocessor knee) and LP 
Torsion foot (K3 foot) requested with CPT codes L5828, L5845, L5848, L5850, L5856, L5920, L5984 and 
L5987. 
 
You asked the Plan to pre-approve the Rheo Knee (K3 microprocessor knee) and LP Torsion foot (K3 foot). 
You say that you would like reconsideration because the requested prosthesis is medically necessary. The Plan 
denied your request. The Plan says the notes do not show any issues with the member's current K3 foot, nor do 
they show that the that cost of repair for current microprocessor knee and K3 foot are more than 60% of 
replacement cost. 
 
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 Rheo Knee (K3 microprocessor 
knee) and LP Torsion foot (K3 foot). Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found the documentation indicates that 
the member is a K3 ambulator and that the health plan has authorized the components of the prosthesis that are 
irreparable.  The documentation does not support that the advanced foot or knee microprocessor require 
replacement or are not functioning correctly. 
 
 
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 Rheo Knee (K3 microprocessor knee) and LP Torsion foot (K3 foot) have 
not been met. Therefore, we decided that the Plan does not have to pre-approve the Rheo Knee (K3 
microprocessor knee) and LP Torsion foot (K3 foot) requested with CPT codes L5828, L5845, L5848, L5850, 
L5856, L5920, L5984 and L5987.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve facet joint interventions. Injection(s), diagnostic or therapeutic 
agent paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance 
(fluoroscopy or CT), lumbar or sacral; single level (64493). 
 
You asked the Plan to pre-approve the facet joint interventions. The Plan denied your request. The Plan says 
that the records do not support the S1 joint as etiology of pain. 
 
 The Plan follows Medicare rules. 
 
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 injection(s), diagnostic or therapeutic 
agent paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance 
(fluoroscopy or CT), lumbar or sacral; single level. Our reviewer says that the facet joint interventions are 
medically reasonable and necessary. Our physician reviewer found the request for all levels is medically 
reasonable and necessary based on the dual innervation of facet joints 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of injection(s), diagnostic or therapeutic agent paravertebral facet (zygapophyseal) 
joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level 
have been met. Therefore, we decided that the Plan has to pre-approve Injection(s), diagnostic or therapeutic 
agent paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance 
(fluoroscopy or CT), lumbar or sacral; single level. (64493). 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) 
provided on January 10, 2022. 
 
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you are being 
overcharged for this service. You also say that this service should be covered by the Plan. The Plan denied your 
request. The Plan says this service is not a covered expense under your dental plan. The Plan also says that you 
did not contact the Plan to verify benefits or provider prior to services being rendered. 
 
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 
problem focused limited oral evaluation (D0140) provided on January 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a non-alignable system. 
 
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 when an above knee preparatory (L5560, L5570, 
L5580, L5590, L5595, L5600) prosthesis is provided, prosthetic substitution and/or additions of procedures and 
components are covered in accordance with the functional level assessment. 
 
We looked at the file and Medicare rules. The enrollee has been approved for a preparatory prosthesis with a 
non-alignable system; therefore, the requested alignable system is not compatible. 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 a non-alignable system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a porcelain/ceramic crown (D2740) and core buildup 
(D2950) for tooth #15. 
 
You asked the Plan to pre-approve a crown and core buildup. You say that these services are medically 
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 
porcelain/ceramic crown (D2740) and core buildup (D2950) for tooth #15.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the partial upper denture (D5213) provided on October 4, 2021. 
 
You asked the Plan to pay for the dental service. You say that you have received mixed messages from your 
plan since your October monthly report indicating you were not responsible for the cost of $1,650. You say that 
you received a denial for the service in January 2022. You say that you have not have a new upper denture in 
20 years. You also say that you do not understand how your coverage has been met. The Plan denied your 
request. The Plan says the $200 dental allowance has been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and dentures are covered, the $200 dental allowance has been exhausted. The record shows that the Plan paid $200 towards a denture repair that 
you received on January 15, 2021. Therefore, we decided that the Plan does not have to pay for the partial 
upper denture (D5213) provided on October 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established 
patient (D0150) provided November 22, 2021. 
 
You asked the Plan to pay for the comprehensive oral exam. You say that your dentist retired and then you 
moved which caused you to need two new patient exams in the same year. The Plan denied your request. The 
Plan says you have exceeded the frequency limit for this 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. The Plan covers the 
comprehensive oral exam once every three plan years. 
 
We looked at the file and Medicare rules. The Plan provided documentation showing that a comprehensive 
exam was previously covered on May 20, 2021. Based on this information, we decided that the Plan's frequency limit for coverage of the comprehensive oral exam has been exceeded. Therefore, we decided that 
the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150) 
provided November 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the filling (D2391) for tooth # 6, filling (D2392) for tooth # 
14, and denture repair (D5610) provided on October 12, 2021. 
 
You asked the Plan to pay for the dental services. You say that the office you called initially advised they could 
not help you. You say that they advised you go to a different office that was not on your list. You also say that 
the work you had done was necessary. The Plan denied your request. The Plan says dental services received out 
of network are not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, dental services received out of network 
are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
the filling (D2391) for tooth # 6, filling (D2392) for tooth # 14, and denture repair (D5610) provided on 
October 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gingival irrigation  per quadrant (D4921) provided 
December 2, 2021. 
 
You asked the Plan to pay for the gingival irrigation. You say that you need this service to be paid to treat your 
gingivitis. The Plan denied your request. The Plan says this service is not covered under this 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 pay for the 
gingival irrigation  per quadrant (D4921) provided December 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown - porcelain/ceramic (D2740), core buildup, 
including any pins when required (D2950) and unspecified preventive procedure, by report (D1999) provided 
June 24, 2021. 
 
You asked the Plan to pay for the crown, core buildup and unspecified preventative procedure. You say that 
you feel these services should be covered. 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 pay for the crown - porcelain/ceramic (D2740), core buildup, including any pins when required (D2950) and unspecified 
preventive procedure, by report (D1999) provided June 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation to be rendered by a periodontist. 
 
You asked the Plan to pre-approve the consultation. You say that you were advised that you have an 11mm 
pocket in tooth #18, and you must see a periodontist for further assistance. The Plan denied your request. The 
Plan says your plan only provides coverage for dental services when they are performed by a participating 
general dentist. The Plan also says that dental services performed by a periodontist are not covered. 
 
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 
covered when they are received by anyone other than a participating general dentist. Therefore, we decided that 
the Plan does not have to pre-approve a consultation to be rendered by a periodontist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a porcelain/ceramic crown (D2740) for tooth #8. 
 
You asked the Plan to pre-approve the crown. You say that the crown is necessary. The Plan denied your 
request. The Plan says crowns 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 
porcelain/ceramic crown (D2740) for tooth #8.