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

 
We decided that the Plan does not have to pre-approve deep sedation/general anesthesia (D9223) X 3, removal 
of lateral exostosis (D7471) X 2, removal of torus mandibularis (D7473), deep sedation/general anesthesia  
first 15 minutes (D9222), therapeutic parenteral drug, single administration (D9610), and therapeutic parenteral 
drugs (D9612). 
 
You asked the Plan to pre-approve the dental services. You say that you are on a fixed income and cannot 
afford these procedures. 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 deep 
sedation/general anesthesia (D9223) X 3, removal of lateral exostosis (D7471) X 2, removal of torus 
mandibularis (D7473), deep sedation/general anesthesia  first 15 minutes (D9222), therapeutic parenteral 
drug, single administration (D9610), and therapeutic parenteral drugs (D9612).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a visual field exam and ophthalmic imaging 
provided on April 27, 2022. 
 
  You asked the Plan to waive the copayment for a visual field exam and imaging. You say that you were told 
you wouldn't have a copayment. The Plan denied your request. The Plan says the refraction has been approved 
and the copayment applied correctly to the visual field exam and ophthalmic imaging. 
 
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 $75 
copayment for diagnostic procedures and tests, including ultrasounds at all locations of service.  
 
You have been asked to pay $68.43, which is less than the standard $75 copayment for a visual field exam and 
ophthalmic imaging. The visual field exam and ophthalmic imaging fall within the Outpatient Diagnostic Tests 
and Therapeutic Services and Supplies 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 a visual field exam and ophthalmic imaging provided on April 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on April 12, 
2022. 
 
You asked the Plan to pay for the periodontal maintenance. You say that you feel the Plan should cover this 
service as a routine cleaning, and you will pay the difference. The Plan denied your request. The Plan says this 
service is not included on 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 pay for the 
periodontal maintenance (D4910) provided on April 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom fabricated knee orthosis. 
 
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 a knee orthosis is 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 show that you have 
had a recent injury or knee surgery. There is no examination showing objective description of looseness of the 
knee joint (joint laxity). There is no deformity of the leg or knee that would require a custom orthosis. The 
criteria are not met and the services are therefore 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 a custom fabricated knee orthosis.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and x-rays performed by a chiropractor on 
April 4, 2022. 
 
You asked the Plan to pay for the office visit and x-rays. You say that you don't understand how the 
chiropractor would treat back pain without the help of an x-ray. The Plan denied your request. The Plan says 
these services are not covered when performed by a chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
  The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for an office visit and x-rays performed by a chiropractor on April 4, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent, paravertebral facet joint 
nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint and each additional 
facet joint (CPT code(s): 64634 x2 and 64633 x2). 
 
You asked the Plan to pre-approve the injections. You say that the injections are necessary. The Plan denied 
your request. The Plan says the enrollee's request is not medically necessary because the enrollee's records 
show they have not had had at least two (2) medically reasonable and necessary diagnostic medial branch blocks (MBBs), with each one providing a consistent minimum of 80% sustained relief of primary (index) 
pain. 
 
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 injections. Our physician reviewer 
found the enrollee has not had a second confirmatory set of diagnostic blocks. Therefore, the request does not 
meet the LCD requirements of two (2) separate sets of diagnostic MBB which achieve 80% pain relief. The 
request is deemed 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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance 
(fluoroscopy or CT); cervical or thoracic, single facet joint and each additional facet joint (CPT code(s): 64634 
x2 and 64633 x2).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97010 billed for date of service April 4, 
2022. 
 
You asked the Plan to pay for procedure code 97010. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says procedure code 97010 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 97010 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 97010 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 97010 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 97010 billed for date of service April 4, 2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Zilretta. 
 
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 that the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 medically necessary. Our physician reviewer found the enrollee has knee osteoarthritis. The 
requested drug is being used for its current Food and Drug Administration (FDA)-labelled indication. The FDA 
has not restricted its use to a single injection. The Zilretta is therefore reasonable and 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 been met. Therefore, we decided that the Plan has to pre-
approve Zilretta.  
 
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 a cone beam computed tomography capture and 
interpretation (D0367) provided on May 12, 2022. 
 
You asked the Plan to pay for a cone beam computed tomography capture and interpretation. You say that the 
service was necessary. The Plan denied your request. The Plan says the service at issue is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a cone 
beam computed tomography capture and interpretation (D0367) provided on May 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on April 18, 
2022. 
 
You asked the Plan to pay for a limited oral evaluation. You say that you want the Plan to pay for this service. 
The Plan denied your request. The Plan says the service at issue is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a limited 
oral evaluation (D0140) provided on April 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an apicoectomy (D3410), and a retrograde filling (D3430) 
provided on April 7, 2022. 
 
You asked the Plan to pay for an apicoectomy, and a retrograde filling. You say that you were advised that you 
would receive reimbursement for services. The Plan denied your request. The Plan says the services at issue are 
not covered services. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an 
apicoectomy (D3410), and a retrograde filling (D3430) provided on April 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), prophylaxis (D1110), 
periapical x-rays (D0220 x 2), and bitewing x-rays (D0274) provided on February 23, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says the dental services were received from an out-of-network provider 
and 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. 
 
The record shows you received the requested 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 pay for a periodic oral evaluation (D0120), prophylaxis (D1110), periapical x-rays (D0220 x 2), and 
bitewing x-rays (D0274) provided on February 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the extractions of teeth numbers 26, 27, 28, 29, and 31 
(D7210). 
 
You asked the Plan to pre-approve the extractions of teeth numbers 26, 27, 28, 29, and 31 (D7210). You say 
that you are appealing with supporting records. 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 after the previous authorization for teeth 
numbers 8, 12, 20, 21, 22, 23, 24, and 25. Therefore, we decided that the Plan does not have to pre-approve the 
extractions of teeth numbers 26, 27, 28, 29, and 31 (D7210).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve all white glass crown tooth (D2740) on teeth six, seven, 
eight, nine, and eleven. 
 
You asked the Plan to pre-approve all white glass crown tooth (D2740) on teeth six, seven, eight, nine, and 
eleven. You say that you need these services done. You also say that you need this part of the services to 
complete the work that is needed to be done. You also say that the roots are starting to get darker as well as 
possibly dying. The Plan denied your request. The Plan says this is not medically necessary. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers all white glass 
crown tooth (D2740) on teeth six, seven, eight, nine, and eleven 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 all white glass crown tooth (D2740) on 
teeth six, seven, eight, nine, and eleven. Our reviewer says that this does not meet criteria. Our physician 
reviewer found in this case, none of the anterior teeth exhibit four or more involved surfaces along with at least 
50 percent of the incisal edge. Our physician reviewer also found that two of the anterior teeth have existing 
crowns that do not show signs of damage or a compromised margin. Our physician reviewer also found that it 
is noted that endodontically treated anterior teeth do not necessarily require a crown if there is sufficient 
structure remaining. Our physician reviewer also found that given the amount of remaining structure on teeth 
number six, seven and eleven, there would not be a clear need for crowns on these teeth, and numbers eight and 
nine have existing crowns that do not appear to be defective and not in need of replacement. 
 
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 all white glass crown tooth (D2740) on teeth six, seven, eight, nine, and eleven 
have not been met. Therefore, we decided that the Plan does not have to pre-approve all white glass crown 
tooth (D2740) on teeth six, seven, eight, nine, and eleven.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for expandable controller, harness for upgrade to expandable 
controller, power seat elevation system, and electronic connection between wheelchair controller and two or 
more power seating system motors. 
 
You asked the Plan to pay for expandable controller, harness for upgrade to expandable controller, power seat 
elevation system, and electronic connection between wheelchair controller and two or more power seating 
system motors. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says 
the requested items are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that power wheelchair accessories are only covered 
for certain indications. A power seat elevation feature is non-covered. 
 
We looked at the file and Medicare rules. Review of the file shows that the enrollee has four out of five right 
upper limb strength. This means the enrollee's right upper limb strength and function are adequate for the 
enrollee to be able to control the power options using their own switches which are included in the allowance 
of the power options. Based on this information, we decided that Medicare rules for coverage of expandable 
controller, harness for upgrade to expandable controller, power seat elevation system, and electronic 
connection between wheelchair controller and two or more power seating system motors have not been met. 
Therefore, we decided that the Plan does not have to pay for expandable controller, harness for upgrade to 
expandable controller, power seat elevation system, and electronic connection between wheelchair controller 
and two or more power seating system motors.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two resin-based composites of one surface (D2330 x2) 
and resin-based composite of two surfaces (D2331) provided on May 12, 2022, by an out-of-network (OON) 
provider. 
 
You asked the Plan to pay for the resin-based composites. The Plan denied your request. The Plan says the 
dental services were received from an out-of-network provider and 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. 
 
The record shows you received the requested 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 pay for the two resin-based composites of one surface (D2330 x2) and resin-based composite of two surfaces 
(D2331) provided on May 12, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete upper denture (D5110) and a complete lower 
denture (D5120) received on January 31, 2022. 
 
You asked the Plan to pay for the dental services. You say that you cannot afford to pay for these 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 your benefit for the requested item or service was exhausted on date of service January 20, 2021. Therefore, we decided that the Plan does not have to pay for a complete upper denture (D5110) and a complete 
lower denture (D5120) received on January 31, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bursectomy for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the documentation does not contain advanced imaging to support diagnosis, and the 
exam is non-specific other than tenderness over trochanter. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that detailed documentation is not evident regarding detailed/comprehensive physical examination 
findings to fully support the greater trochanteric bursa as the cause of the left hip pain. X-rays of the left hip 
show no fractures or dislocations. However, further imaging including ultrasound and/or MRI were not noted 
(to rule out other potential causes of hip pain.) Additionally, she is noted to have had an injection. however, this 
was in 2020, with none more recent. There are limited large-scale, long-term references showing the safety and 
efficacy of the requested surgery in this clinical setting, (as peer-reviewed literature potentially supports 
surgery for cases refractory to conservative treatment and when other potential causes of pain have been reasonably ruled out.) There is no compelling rationale presented or extenuating circumstances noted to support 
the medical necessity of this request as an exception. Therefore, the requested bursectomy of the left hip, 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve bursectomy for the enrollee.