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

 
We decided that the Plan does not have to pre-approve crowns (D2740) for tooth #'s 23 and 25. 
 
You asked the Plan to pre-approve crowns (D2740) for tooth #'s 23 and 25. You say that the crowns you 
currently have are worn down and need to be replaced. 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 when the Plan approved the crowns 
(D2740) for tooth #'s 22 and 27 on August 9, 2022. Therefore, we decided that the Plan does not have to pre-
approve crowns (D2740) for tooth #'s 23 and 25.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an addition to lower extremity, below knee (BK) 
(L5671), an addition to lower extremity, below knee (BK) (L5673), an addition, endoskeletal knee-shin system, 
single (L5828), an addition, endoskeletal knee-shin system, stance (L5845), an addition to endoskeletal knee-
shin system, fluid (L5848), an addition to lower extremity prosthesis (L5856), an all lower extremity 
prostheses, flex-foot system (L5980), an all lower extremity prostheses, flex-walk system (L5981) and an all 
endoskeletal lower extremity prostheses, axial (L5984). 
 
You asked the Plan to pre-approve prosthetics. You say that you do not agree with the denial and are requesting 
reconsideration. The Plan denied your request. The Plan says while the prosthetist alleges that you are a K3 
ambulator, the clinical documentation does not support this. 
 
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 prosthetics. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the records do not support that the advanced K3 level knee and foot and other requested 
equipment at issue in this case meet all Medicare criteria for medically reasonable and necessary for you. 
Although records from the device vendor argue medical necessity of the requested equipment, no records from 
your actual treating provider clarify why the requested equipment is the most appropriate treatment for your 
condition and that you are truly a K3 level ambulator or has the potential to be one. You do not have a below-
the-knee amputation to meet criteria for L5671 and L5673. You have a partial left foot amputation, both L5980 
and L5981 are not appropriate. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of prosthetics have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an addition to lower extremity, below knee (BK) (L5671), an addition to lower extremity, 
below knee (BK) (L5673), an addition, endoskeletal knee-shin system, single (L5828), an addition, 
endoskeletal knee-shin system, stance (L5845), an addition to endoskeletal knee-shin system, fluid (L5848), an 
addition to lower extremity prosthesis (L5856), an all lower extremity prostheses, flex-foot system (L5980), an 
all lower extremity prostheses, flex-walk system (L5981) and an all endoskeletal lower extremity prostheses, 
axial (L5984).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve upper dentures. 
 
You asked the Plan to pre-approve upper dentures. You say that you lost your dentures, and you need to replace 
them. The Plan denied your request. The Plan says upper dentures are not covered. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement 
of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or 
paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve upper dentures.
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 dental services. You say that your current dentures are too big, and you 
cannot wear them. 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 March 11, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat lift chair. 
 
You asked the Plan to pre-approve a seat lift chair. You say that the requesting provider has supplied a letter of 
medically necessity for the requested items. The Plan denied your request. The Plan says the item which 
remains in dispute is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. The rules say that seat lift chairs are not covered. Coverage is limited to a seat lift 
mechanism.  
 
Although a seat lift chair may be appropriate, Medicare does not cover this item and the Plan must provide 
coverage only for items that Medicare covers. The recliner does not serve a purpose that is primarily medical in 
nature. This item is available to the general public and would be helpful even to those who are not sick or 
injured. Therefore, we decided that the Plan does not have to pre-approve a seat lift chair.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional hour of home health aide service per day, 
Monday through Friday. 
 
You asked the Plan to pre-approve an additional hour per day, Monday through Friday. You say that 4 hours 
per day was previously approved for the hours that your doctor requested. You say that you live at home with 
your spouse. You also say that you do not understand why the hours were cut short when this is what has been 
approved in the past. The Plan denied your request. The Plan says the additional hour of home health aide 
services per day, Monday through Friday, is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or 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 an additional hour per day, Monday 
through Friday. Our reviewer says that the requested additional hour per day is not medically necessary. Our 
physician reviewer found the provided documentation does not provide non-custodial care required by the 
enrollee to support 4 hours per day, 5 days per week of home health aide services. Therefore, the additional 
hour per day is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an additional hour per day, Monday through Friday have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an additional hour of home health aide 
service per day, Monday through Friday.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Amnio-Fix allograft. 
 
You asked the Plan to pre-approve Amnio-Fix allograft. You say that this is medically necessary The Plan 
denied your request. The Plan says this procedure 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 Amnio-Fix allograft. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is limited published, large-scale, long-term, peer-reviewed literature that shows 
this to be an effective and/or safe treatment for the noted condition. Further studies are needed to include larger 
cohorts as well as multiple level lumbar fusion. There is no compelling rationale or extenuating circumstance 
noted to support the necessity of this procedure as an exception to guidelines.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Amnio-Fix allograft have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Amnio-Fix allograft.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a gingival irrigation (D4921). 
 
You asked the Plan to pre-approve the gingival irrigation. The Plan denied your request. The Plan says this 
service is not covered under the enrollee's 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 
gingival irrigation (D4921).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve full braces (D8090). 
 
You asked the Plan to pre-approve braces. You say that full braces are medically necessary. The Plan denied 
your request. The Plan says full braces (D8090) 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 full 
braces (D8090).
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 the enrollee lost their dentures, which is 
causing them discomfort and irritability, and you would like them to be replaced. 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 5, 2019. 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 complete maxillary denture (D5110) and a complete 
mandibular denture (D5120). 
 
You asked the Plan to pre-approve the complete dentures. You say that you need these dentures so you can eat. 
The Plan denied your request. The Plan says these 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. 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 an endosteal implant on tooth #20 (D6010), 
prefabricated abutment on tooth #20 (D6056), and an abutment supported crown on tooth #20 (D6062). 
 
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 that there is more than one missing tooth in the arch. 
 
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 dental 
services when the services are medically necessary and reasonable.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the dental services. Our reviewer says 
that the coverage criteria has not been met. Our physician reviewer found that there are several missing teeth in 
the same arch, including #30, and what appears to be #20 as well as #19. Due to Plan limitations, the criteria 
for a single tooth implant has not been met. 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 the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an endosteal implant on tooth #20 (D6010), prefabricated abutment on tooth #20 
(D6056), and an abutment supported crown on tooth #20 (D6062).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retainer crowns on tooth #2 and 4 (D6740) and a pontic 
on tooth # 3 (D6245). 
 
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 retainer crowns (D6740) and a pontic (D6245) 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 
retainer crowns on tooth #2 and 4 (D6740) and a pontic on tooth # 3 (D6245).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an occlusal guard (D9944). 
 
You asked the Plan to pre-approve an occlusal guard. The Plan denied your request. The Plan says the 
requested service is not a covered benefit 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 an 
occlusal guard (D9944).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown on tooth #15 (D2740). 
 
You asked the Plan to pre-approve a crown. You say that the tooth can be saved. The Plan denied your request. 
The Plan says that the tooth does not appear to have 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 insufficient damage to tooth #15 
to require a crown, along with the subordinate core restoration. A conventional restoration would appear to be 
adequate to restore the tooth. 
 
 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 #15 (D2740).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve six physical therapy visits. 
 
You asked the Plan to pre-approve therapy visits. You say that additional therapy is medically necessary. The 
Plan denied your request. The Plan says the remaining six physical therapy visits are not medically necessary. 
 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 therapy 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 that you have made improvements in terms of mobility and additional 
progress can be accomplished in the context of a home exercise program. This can be accomplished with the 
approved additional six physical therapy visits. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of therapy visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve six physical therapy visits.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve allograft for spine surgery only, InQu Allograft (20930). 
 
You asked the Plan to pre-approve InQu allograft. You say that the attached are physical therapy notes as well 
as additional clinicals for medical necessity. 
 The Plan denied your request. The Plan says the clinical value and effectiveness of Isto Biologics, InQu 
allograft in the setting of lumbar spinal fusion surgery have 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 InQu allograft. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found however, there is limited published, large-scale, long-term peer-reviewed literature that shows 
this request to be an effective and/or safe treatment for the noted pathology. Further studies are needed to 
confirm the early findings as well as studies evaluating its clinical success for one- and two-level 
transforaminal lumbar interbody fusion procedures. There is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested 
InQu Allograft for spine surgery, 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 InQu allograft have not been met. Therefore, we decided that the Plan does not 
have to pre-approve allograft for spine surgery only, InQu Allograft (20930).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone replacement graft for ridge preservation per site 
(D7953) Tooth # 3 and 11. 
 
You asked the Plan to pre-approve bone replacement graft for ridge preservation per site (D7953) Tooth # 3 
and 11. You say that the procedure is needed, you are in so much pain it is intolerable. 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 bone replacement graft 
for ridge preservation per site (D7953) is not among those covered under this benefit. Therefore, we decided 
that the Plan does not have to pre-approve bone replacement graft for ridge preservation per site (D7953) Tooth 
# 3 and 11.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement graft (D4263), two endosteal 
implants (D6010 x2), two surgical accesses to implant bodies (D6011 x2), and two implant supported 
porcelain/ceramic crowns (D6065 x2). 
 
You asked the Plan to pre-approve a bone replacement graft, endosteal implants, surgical accesses to implant 
bodies, and implant supported crowns. You say that you need these implants for tooth #'s 13 and 30. You also 
say that your dentist said without them, your teeth will shift. The Plan denied your request. The Plan says these 
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. Therefore, we decided that the Plan does not have to pre-approve a 
bone replacement graft (D4263), two endosteal implants (D6010 x2), two surgical accesses to implant bodies 
(D6011 x2), and two implant supported porcelain/ceramic crowns (D6065 x2).