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

 
We decided that the Plan does not have to pre-approve prefabricated abutment (D6056) and implant supported 
porcelain/ceramic crown. 
 
You asked the Plan to pre-approve prefabricated abutment (D6056) and implant supported porcelain/ceramic 
crown. You say that you were already approved for the dental services. The Plan denied your request. The Plan 
says these dental services are not covered under the 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 
prefabricated abutment (D6056) and implant supported porcelain/ceramic crown.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown on tooth #24 and 25 (D2740). 
 
You asked the Plan to pre-approve crowns. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that teeth #24 and 25 do 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 crowns 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 crowns. Our reviewer says that the 
coverage criteria has not been met. Our physician reviewer found that the documentation provided shows that 
teeth #24 and 25 do not exhibit significant coronal breakdown due to caries or fracture to warrant crown 
restorations. 
 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 crowns have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a crown on tooth #24 and 25 (D2740).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a porcelain crown fused to high noble metal for tooth 
#18 (D2750). 
 
You asked the Plan to pre-approve a porcelain crown. You say that the crown is medically necessary for your 
quality of life. You say the filling is not holding well and needs to be replaced with a crown as soon as possible 
or you will be unable to chew properly. The Plan denied your request. The Plan says the decision to deny pre-
approval of a porcelain crown was correct. The Plan states that porcelain crowns are 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 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 a 
porcelain crown fused to high noble metal for tooth #18 (D2750).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), teeth cleaning 
(D1110), intraoral periapical radiographic images (D0220, D0230 x4), and cleaning and inspection of 
removable upper denture (D9932) provided on December 30, 2021. 
 You asked the Plan to pay for the dental services. You say that you want the Plan to pay for these services. The 
Plan denied your request. The Plan says you are responsible for services provided by privately contracted 
providers. The Plan will not reimburse for charges incurred by Medicare opt out providers. 
 
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.  
 
We looked at 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. Specifically, services were provided by an opt out provider. 
The Plan does not cover dental services when provided by an opt out provider. Therefore, we decided that the 
Plan does not have to pay for a comprehensive oral evaluation (D0150), teeth cleaning (D1110), intraoral 
periapical radiographic images (D0220, D0230 x4), and cleaning and inspection of removable upper denture 
(D9932) provided on December 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral complete series of radiographic images (D0210) 
and an occlusal guard (D9944) provided from March 16, 2021, through October 7, 2021. 
 
You asked the Plan to pay for the dental services. You say that the services were for medical purposes and 
should be covered. The Plan denied your request. The Plan says the services at issue are not covered 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 an 
intraoral complete series of radiographic images (D0210) and an occlusal guard (D9944) provided from March 
16, 2021, through October 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extractions (D7210 x11), general anesthesia (D9222, 
D9223), and drug injections (D9610, D9612) provided on March 23, 2022, by an out-of-network provider. 
 
You asked the Plan to pay for the dental services. You say that you want the Plan to pay for these 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 extractions (D7210 x11), general anesthesia (D9222, D9223), and drug injections (D9610, D9612) 
provided on March 23, 2022, by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implanted supported crown (D6066), an endosteal 
implant (D6010), prefabricated abutment (D6056), and a bone replacement graft (D7953), provided by a 
participating provider. 
 
You asked the Plan to pre-approve an implanted supported crown, an endosteal implant, prefabricated 
abutment, and a bone replacement graft. You say that your tooth broke, and an implant is the best replacement. 
The Plan denied your request. The Plan says the requested services are not covered 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 an implanted supported crown (D6066), an endosteal implant (D6010), prefabricated abutment (D6056), and a 
bone replacement graft (D7953), provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an occlusal guard  hard appliance, full arch (D9944). 
 
You asked the Plan to pre-approve an occlusal guard. You say that the enrollee needs this service. The Plan 
denied your request. The Plan says this service is not covered under the enrollee's 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 an 
occlusal guard  hard appliance, full arch (D9944).
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 (D0364) provided on February 10, 2022. 
 
You asked the Plan to pay for a cone beam computed tomography capture and interpretation. 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 cone 
beam computed tomography capture and interpretation (D0364) provided on February 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a consultation (D9310) provided on March 8, 2022. 
 
You asked the Plan to pay for a consultation. You say that you were told the service would be covered at 50%. 
The Plan denied your request. The Plan says the service at issue is not covered under any circumstance. 
 
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 
consultation (D9310) provided on March 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crown - porcelain fused to high noble metal (D2750) on 
tooth #'s 5 and 29, core buildup (D2950) on tooth #'s 5, 14, 20 & 29, unspecified fixed prosthodontic procedure 
(D6999) on tooth #'s 5, 14, 20 & 29 and crown - porcelain/ceramic (D2740) on tooth #'s 14 & 20. 
 
You asked the Plan to pre-approve the dental services. You say that you have stage 4 cancer and require 
treatment orally and by infusion. The Plan denied your request. The Plan says these services are not covered 
services 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 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 
crown - porcelain fused to high noble metal (D2750) on tooth #'s 5 and 29, core buildup (D2950) on tooth #'s 5, 
14, 20 & 29, unspecified fixed prosthodontic procedure (D6999) on tooth #'s 5, 14, 20 & 29 and crown - 
porcelain/ceramic (D2740) on tooth #'s 14 & 20.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve debridement and bone contouring of a peri-implant 
defect of tooth #14 (D6102) and autogenous connective tissue graft procedure of tooth #14, #24, and #25 
(D4273). 
 
You asked the Plan to pre-approve the dental services. You say that the old implants are popping through your 
gums, and you might lose three teeth if left untreated. The Plan denied your request. The Plan says the 
requested services were denied appropriately. The contract clearly states codes that are not included in the list 
of covered dental procedures are excluded from coverage. 
 
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 
debridement and bone contouring of a peri-implant defect of tooth #14 (D6102) and autogenous connective 
tissue graft procedure of tooth #14, #24, and #25 (D4273).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve osseous surgery (D4260, D4261) and an occlusal 
adjustment (D9951). 
 
You asked the Plan to pre-approve the dental services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says osseous surgery (D4260, D4261) and an occlusal adjustment (D9951) 
are not covered by your routine 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 
osseous surgery (D4260, D4261) and an occlusal adjustment (D9951).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), and an intraoral 
periapical radiographic image (D0230) provided on January 24, 2022. 
 
You asked the Plan to pay for the dental services. You say that this a new policy and the services should be 
covered. 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 comprehensive oral evaluation was exhausted on date of service January 28, 2021 
and your benefit for the intraoral periapical radiographic image was exhausted on January 24, 2022. Therefore, 
we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), and an intraoral 
periapical radiographic image (D0230) provided on January 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mandibular partial denture (D5213). 
 
You asked the Plan to pre-approve a partial denture. You say that this service is medically necessary. The Plan 
denied your request. The Plan says a mandibular partial denture (D5213) is not covered by your routine dental 
benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
mandibular partial denture (D5213).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of an impacted tooth - completely bony 
(D7240). 
 
You asked the Plan to pre-approve the removal of an impacted tooth - completely bony (D7240). You say that 
your tooth is bothering you and can cause you pain as the tooth is sideways. The Plan denied your request. The 
Plan says this service is 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 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 the 
removal of an impacted tooth - completely bony (D7240).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on March 29, 2022. 
 
You asked the Plan to pay for the dental services. You say that the service was necessary. 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 Plan's 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 25, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on 
March 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a consultation (D9310) provided on February 26, 2022, by an 
out-of-network provider. 
 
You asked the Plan to pay for the dental services. You say that you were not aware that the provider was out-
of-network. 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 Plan's 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 consultation (D9310) provided on February 26, 2022, by an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Methotrexate. 
 
You asked the Plan to pre-approve Methotrexate. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested drug is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Methotrexate.  
 
Benefits for Methotrexate may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Euflexxa. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has osteoarthritis of the knee. The documentation does not support that the enrollee has tried 
and failed Orthovisc OR Supartz FX. The documnetation does not support that Orthovisc OR Supartz FX 
would likely be less effective and/or likely have adverse effects for the enrollee. Therefore, the enrollee does 
not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp. 
 
You asked the Plan to pre-approve Aranesp. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested Aranesp is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Erythropoietin stimulating agents (ESAs) are a 
covered benefit to treat patients who have one of the FDA approved conditions, and have either symptomatic 
anemia or are transfusion dependent: 
 
Group A: End Stage Renal Disease (ESRD) ON Dialysis 
Group B: Chronic Kidney Disease (CKD) NOT on Dialysis 
Group C: Indications other than Renal Disease 
 
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 Aranesp. Our reviewer says that the 
documentation does not support that Aranesp is not medically necessary. Our physician reviewer found the 
enrollee has a diagnosis of laryngeal carcinoma not on chemotherapy and anemia presumed secondary to 
myelodysplastic syndrome of unknown risk status. The Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's condition. Therefore, the enrollee does not meet criteria for the 
requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp.