Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate. 
 
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 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has lumbar degenerative 
disc disease and lumbar radiculopathy. The requested bone marrow aspirate remains experimental in nature, as 
more research is needed when used as a bone driver. 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 bone marrow aspirate.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient admission for shoulder joint replacement 
surgery. 
 
You asked the Plan to pre-approve inpatient admission. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested services are 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 inpatient admission. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has diagnoses of atrial fibrillation, hypertension, ischemic heart disease, 
gastroesophageal reflux disease and osteoarthritis of the left shoulder. The documentation supports that the 
shoulder replacement surgery may be safely performed with an observational stay. Therefore, the inpatient 
services are not 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 inpatient admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve inpatient admission for shoulder joint replacement surgery.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endosteal implants (D6010) for teeth # 22 and 26, bone 
graft at time of implant placement (D6104) for teeth # 20 and 21, custom fabricated abutment (D6057) for teeth 
# 22 and 26, and implant supported removable denture (D6111) for tooth # 20. 
 
You asked the Plan to pre-approve the dental services. You say that the requested services are necessary to 
ensure the enrollee's quality of life. You say that the enrollee's anatomy is not suitable for tissue supported 
complete lower denture. The Plan denied your request. The Plan says the criteria have not been met. 
 
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 requested services are not medically necessary. Our physician reviewer found the provided 
documentation does not include a specific account of the treatment plan. Without this information, an accurate 
assessment of the coverage cannot be determined. Therefore, the reviewer found that the requested services are 
not medically reasonable and necessary. 
 
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 endosteal implants (D6010) for teeth # 22 and 26, bone graft at time of implant 
placement (D6104) for teeth # 20 and 21, custom fabricated abutment (D6057) for teeth # 22 and 26, and 
implant supported removable denture (D6111) for tooth # 20.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve oral surgery to replace missing teeth (21248). 
 
You asked the Plan to pre-approve oral surgery services. You say that these services are necessary due to 
previous radiation treatment. The Plan denied your request. The Plan says this service is not covered by 
Medicare or your dental benefit. 
 
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 oral surgery to replace 
missing teeth (21248).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for office visit provided on December 21, 2021.

You asked the Plan to waive the copayment for office visit. You say that this charged should be covered since you met your out-of-pocket maximum. The Plan denied your request. The Plan says at the time this claim was received your out-of-pocket maximum had not been reached and the copayment applied is correct.

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 $30 copayment for obtained from a specialist, or under certain circumstances, treatment by a nurse practitioner or physician's assistant or other non-physician health care professionals in a specialist's office (as permitted under Medicare rules).

You have been asked to pay $21.79, which is less than the standard $30 copayment for office visit. Office visit falls within the Physician/Practitioner Services, Including Doctor's Office Visits benefit category. The records show your out-of-pocket maximum was not met at the time this claim was received. 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 office visit provided on December 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crowns (D2750) for teeth # 6 and 21, and a lower partial 
denture (D5214). 
 
You asked the Plan to pre-approve the dental services. You say that you want these services to be covered. The 
Plan denied your request. The Plan says crowns are covered once per tooth every 60 months. The Plan says that 
the frequency limit has been reached. The Plan also says that lower partial denture is not 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 Plan's coverage rules apply in this case. 
 Though the Plan offers a dental benefit in excess of Medicare coverage and crowns are listed as covered, the 
frequency limit of once per tooth every 60 months has been exceeded. The record shows that the Plan paid for a 
crown for tooth # 6 that you received on January 23, 2021, and a crown for tooth # 21 that you received on 
January 8, 2022. Additionally, the requested lower partial denture is not among those covered under this 
benefit. Therefore, we decided that the Plan does not have to pre-approve crowns (D2750) for teeth # 6 and 21, 
and a lower partial denture (D5214).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the deductible for a dermatology specialist office visit provided on January 18, 2022.

You asked the Plan to reduce the deductible for a specialist office visit. You say that you received a bill showing the insurance company paid nothing on the $95.07 charge and did not provide an explanation. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is $110 deductible which applies to a specialist office visit. 

The record shows this claim was approved, and you have a cost sharing amount. The item or service you asked the Plan to reduce the deductible for falls within the Physician/Practitioner Services, Including Doctor's Office Visits benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $110 deductible which applies to a specialist office visit. This cost sharing is a contractual obligation that had not been met at the time a specialist office visit was received on January 18, 2022. Therefore, we decided that the Plan does not have to reduce the deductible for a dermatology specialist office visit provided on January 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete dentures (D5110, D5120) to be provided by an 
out-of-network provider. 
 
You asked the Plan to pre-approve out-of-network dental care. You say that you were unhappy with your 
previous dentures and would like a new set from a new provider. The Plan denied your request. The Plan says 
the provider requested in this case is not part of the Plan's dental network. Your contract requires dental 
services be obtained from a participating/in-network dental provider. 
 
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, items or services from out-of-network 
providers are not covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
complete dentures (D5110, D5120) 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 incisional biopsy of oral tissue (D7286) provided by a 
participating provider. 
 
You asked the Plan to pre-approve incisional biopsy of oral tissue. You say that you would like the Plan to pay 
for this. The Plan denied your request. The Plan says D7286 is not a covered 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 
incisional biopsy of oral tissue (D7286) provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve scaling and root planing (D4341) for the upper left and 
upper right quadrants. 
 
You asked the Plan to pre-approve the dental services. You say that the services are medically necessary. The 
Plan denied your request. The Plan says scaling and root planing is covered once every 3 calendar years per 
quadrant. The Plan also says that the frequency limit has been reached. 
 
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 scaling and root planing is listed as 
covered, the frequency limit has been exceeded. Scaling and root planing is covered once per quadrant every 3 
calendar years. The record shows that the Plan paid for scaling and root planing for the upper left and upper 
right quadrants that you received on August 10, 2020. Therefore, we decided that the Plan does not have to pre-
approve scaling and root planing (D4341) for the upper left and upper right quadrants.
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 a denture. You say that your current denture has broken and needs to be 
replaced. The Plan denied your request. The Plan says you previously received a complete upper denture in 
November of 2018, which is less than five years before this request. Dentures are covered once every 5 years. 
 
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 partial or 
dentures, 1 per 5 years. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the documentation supports that this 
denture is requested in a frequency that is not covered under this benefit. 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 implant placements (D6010) for teeth #22 and #27 and 
modification of a removable prosthesis (D5875). 
 
You asked the Plan to pre-approve dental services. You say that these services are 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 
implant placements (D6010) for teeth #22 and #27 and modification of a removable prosthesis (D5875).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of an impacted tooth (D7240), collection and 
application of autologous blood concentrate (D7921), and unlisted preventive service (D1999). 
 
You asked the Plan to pre-approve the dental services. You say that you need your tooth to be removed. You 
say that it is infected. You say that you are not able to eat as well because of the pain. You also say that these 
services should be covered. The Plan denied your request. The Plan says the requested services are not listed as 
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 removal of impacted 
tooth, collection and application of autologous blood concentrate and unlisted preventive service are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve removal of 
an impacted tooth (D7240), collection and application of autologous blood concentrate (D7921), and unlisted 
preventive service (D1999).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implant-supported crowns (D6065) for three teeth. 
 
You asked the Plan to pre-approve implant-supported crowns. You say that these services are necessary. The 
Plan denied your request. The Plan says these services are not covered by your dental benefit under any 
condition. 
 
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 
implant-supported crowns (D6065) for three teeth.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) to be provided 
by an oral surgeon. 
 
You asked the Plan to pre-approve the dental service. You say that your general dentist referred you to this 
provider. The Plan denied your request. The Plan says services must be performed by a participating general 
dentist. The Plan also says that services to be performed by an oral surgeon 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 service is not among 
those covered under this benefit when performed by an oral surgeon. Therefore, we decided that the Plan does 
not have to pre-approve a comprehensive oral evaluation (D0150) to be provided by an oral surgeon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341) provided 
by a participating provider. 
 
You asked the Plan to pre-approve periodontal scaling and root planing. You say that you would like the Plan 
to approve and pay for this. The Plan denied your request. The Plan says the enrollee is not enrolled in a dental 
rider. 
 
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 periodontal scaling and 
root planing (D4341) provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete lower denture (D5120). 
 
You asked the Plan to pre-approve a denture. You say that your current denture is broken and needs to be 
replaced. The Plan denied your request. The Plan says you previously received a lower denture for this jaw in 
January of 2018, which is less than five years before this request. Dentures are covered once every five years. 
 
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. The Plan covers full or partial 
dentures, 1 per 5 years. 
 
Though the Plan offers a supplemental benefit in excess of Medicare coverage, the documentation shows that 
the denture is requested in a frequency that is not covered by this benefit. Therefore, we decided that the Plan 
does not have to pre-approve a complete lower denture (D5120).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation feature (E2300). 
 
You asked the Plan to pre-approve a power seat elevation feature (E2300). You say that the requested power 
seat elevation feature (E2300) is medically necessary. The Plan denied your request. The Plan says a power 
seat elevation system (E2300) is statutorily non-covered by Medicare and the Plan. 
 
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. Medicare specifically excludes coverage of power seat elevation 
systems coded as E2300. Therefore, we decided that the Plan does not have to pre-approve a power seat 
elevation feature (E2300).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implant-supported crowns (D6065) for 11 teeth. 
 
You asked the Plan to pre-approve implant-supported crowns. You say that these services are necessary and 
should be covered. 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 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 pre-approve 
implant-supported crowns (D6065) for 11 teeth.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a removable unilateral partial denture for the lower jaw 
(D5283). 
 
You asked the Plan to pre-approve the denture. You say that this service is necessary. The Plan denied your 
request. The Plan says this type of denture is not covered by your dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
removable unilateral partial denture for the lower jaw (D5283).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a resin-based composite (D2392) for tooth #20, 
provided by a participating provider. 
 
You asked the Plan to pre-approve a resin-based composite. You say that you need this filling, so you won't 
need a root canal. The Plan denied your request. The Plan says the benefit limit for D2392 for tooth #20 has 
already been met and 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. The Plan covers one resin-
based composite per tooth every 24 months. 
 
We looked at the file and Medicare rules. Evidence was provided to show that D2392 was provided on May 26, 
2021. Based on this information, we decided that the Plan's rules for coverage of a resin-based composite 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a resin-based composite 
(D2392) for tooth #20, provided by a participating provider.