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

 
We decided that the Plan does not have to pre-approve bone marrow aspirate for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the clinical value and effectiveness of bone marrow aspirate in the 
setting of 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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Bone marrow 
aspirate remains experimental. More research is needed. Our physician reviewer found that the enrollee's 
condition does not meet criteria for coverage of these services. 
 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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on 
March 1, 2022. 
 
You asked the Plan to pay for the comprehensive oral evaluation. You say that you feel you should not be held 
responsible for this charge because you were not advised it would not be covered. The Plan denied your 
request. The Plan says this service exceeds the maximum allowed per period. 
 
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, comprehensive oral evaluation 
(D0150) is limited to one procedure every three plan years. The record shows that you received a 
comprehensive oral evaluation (D0150) on September 22, 2020 and your comprehensive oral evaluation 
(D0150) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the 
comprehensive oral evaluation (D0150) provided on March 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the consultation (D9310) and clinical crown lengthening 
(D4249) provided on November 30, 2021, and December 15, 2021. 
 
You asked the Plan to pay for the consultation and clinical crown lengthening. You say that on November 30, 
2021 you were advised that the treating provider was in the process of becoming affiliated with your plan. You 
also say that on December 15, 2021 you went forward with the dental work because you were in a lot of 
discomfort and pain. The Plan denied your request. The Plan says these services are not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
consultation (D9310) and clinical crown lengthening (D4249) provided on November 30, 2021, and December 
15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gingival irrigation (D4921 x 4) provided on March 7, 2022. 
 
You asked the Plan to pay for gingival irrigation. You say that your dentist told you this was part of your 
cleaning and check-up. The Plan denied your request. The Plan says gingival irrigation (D4921) 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 pay for gingival 
irrigation (D4921 x 4) provided on March 7, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the enrollee is an active 97-year young woman who has been living at home independently along with her sister and would like to continue doing so. The Plan denied your request. The Plan says the information we have about the enrollee's condition does not meet the requirements for IRF admission.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. 
Our physician reviewer found the enrollee was admitted for rib fractures, urinary tract infection, and a small pulmonary embolism. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. Medically necessary care can be provided in a different level of care.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis 
(D1110) provided on June 9, 2021. 
 
You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that due to dental issues 
you need cleanings 3 to 4 times per year. You also say that you have a separate dental policy that covers 
cleanings twice per year. The Plan denied your request. The Plan says there is a limit on the number of times 
these services can be paid for in a calendar year. The Plan also says those limits have already been reached. 
 
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, you are limited to one oral exam per 
calendar year and one routine cleaning per calendar year. The record shows that you received a periodic oral 
evaluation (D0120) and prophylaxis (D1110) on February 1, 2021 and your oral exam and routine cleaning 
benefits had been exhausted. Therefore, we decided that the Plan does not have to pay for the periodic oral 
evaluation (D0120) and prophylaxis (D1110) provided on June 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the repair and/or reline of occlusal guard (D9942) provided 
on March 2, 2022. 
 
You asked the Plan to pay for the repair and/or reline of occlusal guard. You say that you got an occlusal guard 
fixed, but the treating provider was out-of-network and used a non-covered code. The Plan denied your request. 
The Plan says this 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 pay for the repair 
and/or reline of occlusal guard (D9942) provided on March 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213) and a mandibular 
partial denture (D5214). 
 
You asked the Plan to pre-approve the partial dentures. The Plan denied your request. The Plan says these 
services are not covered under the enrollee's 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 
maxillary partial denture (D5213) and a mandibular partial denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2751) and a core buildup (D2950), provided by a 
participating provider. 
 
You asked the Plan to pay for a crown and a core buildup. You say that your teeth are breaking, and you need 
the crowns. The Plan denied your request. The Plan says this appeal has been processed correctly. 
 
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 four crowns 
per calendar year. A core buildup is not a covered benefit. 
 
We looked at the file and Medicare rules. The benefit limit for D2751 has already been met and exhausted. 
D2950 is not a covered dental benefit. Based on this information, we decided that the Plan's rules for coverage 
of a crown and a core buildup have not been met. Therefore, we decided that the Plan does not have to pay for 
a crown (D2751) and a core buildup (D2950), provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a porcelain/ceramic crown (D2740), a core buildup, 
including any pins when required (D2950), and endodontic therapy, of an anterior tooth (excluding final 
restoration) (D3310). 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says these services are not a covered benefit under your 
contractual policy. 
 
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 services are not among 
those covered under this benefit.  Therefore, we decided that the Plan does not have to pre-approve a 
porcelain/ceramic crown (D2740), a core buildup, including any pins when required (D2950), and endodontic 
therapy, of an anterior tooth (excluding final restoration) (D3310).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom fabricated abutments (D6057 x 2) and abutment 
supported porcelain/ceramic crowns (D6058 x 2). 
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says these items are not a covered benefit under your 
contractual policy. 
 
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 are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve custom 
fabricated abutments (D6057 x 2) and abutment supported porcelain/ceramic crowns (D6058 x 2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740), a core build-up (D2950), and 
gingivectomy (D4211), provided by a participating provider. 
 
You asked the Plan to pre-approve a crown, a core build-up, and gingivectomy. You say that you would like 
the Plan to pay for this. The Plan denied your request. The Plan says these services have been processed 
correctly. 
 
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 up to a $1,500 
maximum amount for covered dental services. 
 
We looked at the file and Medicare rules. The enrollees annual maximum dental allowance has already been 
met and exhausted. D4211 is not a covered dental benefit. Based on this information, we decided that the Plan's 
rules for coverage of a crown, a core build-up, and gingivectomy have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a crown (D2740), a core build-up (D2950), and gingivectomy 
(D4211), provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve the maxillary partial denture (dental code D5213) and the 
mandibular partial denture (dental code D5214). 
 
You asked the Plan to pre-approve the maxillary partial denture and the mandibular partial denture. You say 
that the provider would like for you to have no teeth in order to get dentures and you feel that you should not 
have to get healthy teeth pulled for fake teeth. The Plan denied your request. The Plan says that they denied the 
upper false teeth and lower false teeth because it was not medically necessary; the remaining teeth do not show 
healthy gums and good bone support. 
 
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 maxillary 
partial denture and the mandibular partial denture 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 maxillary partial denture and the 
mandibular partial denture. Our reviewer says that the service is medically necessary. Our physician reviewer 
found that review of the documentation indicates that the patient is in need of an extraction (tooth #3) and has 
multiple missing maxillary and mandibular teeth. The remaining maxillary and mandibular teeth appear to have 
adequate bone around teeth that would be used as abutments for the partials. Partial dentures are medically 
reasonable and necessary to provide adequate masticatory function. 
 
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 maxillary partial denture and the mandibular partial denture have been met. 
Therefore, we decided that the Plan has to pre-approve the maxillary partial denture (dental code D5213) and 
the mandibular partial denture (dental code D5214).  
  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 resin-based composites (D2391 and D2392) provided by an 
out-of-network provider on March 22, 2022. 
 
You asked the Plan to pay for resin-based composites. You say that you did not know this provider was out-of-
network until after you had your fillings. The Plan denied your request. The Plan says services provided by an 
out-of-network provider are not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers resin-based 
composites when the services are provided by a participating provider. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of resin-based composites have not been met. Therefore, we decided that the Plan does not have to 
pay for resin-based composites (D2391 and D2392) provided by an out-of-network provider on March 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental office visit. 
 
You asked the Plan to pre-approve an office visit. You say that you would like to appeal the denial of the claim. 
The Plan denied your request. The Plan says you are not covered for this service with 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 a 
dental office visit.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite (D2392) provided by an out-of-
network provider on March 18, 2022. 
 
You asked the Plan to pay for a resin-based composite. You say that you have never had a problem with getting 
your dental work paid for before. You say that you did not know this provider was out-of-network. The Plan 
denied your request. The Plan says services provided by an out-of-network provider are not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a resin-based 
composite when the services are medically necessary and reasonable.  

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 resin-based composite have not been met. Therefore, we decided that the Plan 
does not have to pay for a resin-based composite (D2392) provided by an out-of-network provider March 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve comprehensive oral evaluation (D0150) and unspecified 
endodontic procedure (D3999). 
 
You asked the Plan to pre-approve comprehensive oral evaluation (D0150) and unspecified endodontic 
procedure (D3999). You say that you were advised you had an infection and abscess in your gums. The Plan 
denied your request. The Plan says services are not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. The requested comprehensive oral evaluation and endodontic 
procedure are not covered under Original Medicare. Therefore, we decided that the Plan does not have to pre-
approve comprehensive oral evaluation (D0150) and unspecified endodontic procedure (D3999).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an out-of-network provider on 
October 29, 2021, to December 3, 2021. 
 
You asked the Plan to pay for dental services. You say that there is a new owner at your dental office. You say 
that you were never told that the new dentist was out-of-network. The Plan denied your request. The Plan says 
services provided by an out-of-network provider 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. The Plan covers covered 
dental services when the services are provided by a participating provider. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of dental services have not been met. Therefore, we decided that the Plan does not have to pay for 
dental services provided by an out-of-network provider on October 29, 2021, to December 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the full mouth debridement (D4355) provided on March 18, 2022. 
 
You asked the Plan to pay for the full mouth debridement. You say that your dentist's office verified your 
insurance plan before accepting your appointment for a cleaning. The Plan denied your request. The Plan says 
this service is 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the full 
mouth debridement (D4355) provided on March 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a free soft tissue graft procedure (D4278) for tooth #26. 
 
You asked the Plan to pre-approve the free soft tissue graft procedure. You say that the recommended 
treatment is necessary as a gingival graft can help slow down further recession and bone loss on tooth #'s 23, 
24, 25, and 26. You also say that periodontal health could be improved on tooth #'s 23, 24, 25, and 26, and 
future care cost would be reduced. The Plan denied your request. The Plan says this request has exceeded the 
limits. 
 
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, payment for periodontal soft tissue 
grafts is limited to three teeth per graft. The record shows that grafts were approved for tooth #'s 23 (D4277), 
24 (D4278), and 25 (D4278), and your periodontal soft tissue grafts for this site have been exhausted. 
Therefore, we decided that the Plan does not have to pre-approve a free soft tissue graft procedure (D4278) for 
tooth #26.