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

 
We decided that the Plan does not have to pre-approve a partial denture for the lower jaw (D5214). 
 
You asked the Plan to pre-approve a partial denture. You say that you were told by an insurance agent that this 
service would be covered. The Plan denied your request. The Plan says dentures 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 a 
partial denture for the lower jaw (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental extraction (D7210) to be provided by an oral 
surgeon. 
 
You asked the Plan to pre-approve dental care to be performed by an oral surgeon. You say that you were 
uncomfortable during the previous extractions you received, and you would like this next extraction to be 
provided by an oral surgeon. The Plan denied your request. The Plan says services are only covered when they 
are performed by a participating general dentist. An oral surgeon is a dental specialist, and therefore services 
from 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. The Plan covers certain dental 
services when they are performed by a participating general dentist. 
 
We looked at the file and the Plan's rules. The requested provider in this case is not a general dentist. Based on 
this information, we decided that the Plan's rules for coverage of dental care to be performed by an oral surgeon 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a dental extraction 
(D7210) to be provided by an oral surgeon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a removal of lateral exostosis (D7471). 
 
You asked the Plan to pre-approve the removal of lateral exostosis. You say that you are a diabetic and have 
bone in your gum that hurts when you chew. 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 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 
removal of lateral exostosis (D7471).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) and 22 
extractions (D7210) to be provided by an oral surgeon. 
 
You asked the Plan to pre-approve the dental services. You say that your general dentist determined your teeth 
were not salvageable. You also say that you need to be sedated due to your medical conditions. The Plan 
denied your request. The Plan says dental services must be performed by a participating general dentist. The 
Plan also says that services 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 services to be performed 
by an oral surgeon are not covered are not among those covered under this benefit. Therefore, we decided that 
the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) and 22 extractions (D7210) to 
be provided by an oral surgeon.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99497 billed for date of service June 5, 2021. 
 
You asked the Plan to pay for procedure code 99497. You say that you have provided medical records to 
support payment of this service. The Plan denied your request. The Plan says the medical records do not 
support code 99497. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99497 is advance care planning including the explanation 
and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, 
family member(s), and/or surrogate.  
 
We find that CPT code 99497 is not supported in the medical record. Specifically billing of this code requires 
documentation of an account of the discussion with the patient (or family member/surrogate) regarding the 
nature of the encounter.  It also requires documentation of explanations of advanced directives, who was 
present during the visit, and the time spent in the face-to-face encounter.  The medical records from the June 5, 
2021, include none of these pieces of information. The note from this date of service simply states the 
following: "Patient seen examined. Patient was started back on Seroquel last night this morning.  She is more 
sedated. Discussed with daughter will cut back to 125mg per day.  Patient was very aggressive yesterday 
without the Seroquel." There is no documentation of any discussion of advance care planning, and there was no 
notation as to how long this encounter lasted.   
 
Based on this information, we decided that Medicare rules for coverage of procedure code 99497 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 99497 billed for date of 
service June 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve three prefabricated abutments (D6056 x3) and three 
abutment supported porcelain/ceramic crowns (D6058 x3). 
 
You asked the Plan to pre-approve the prefabricated abutments and abutment supported porcelain/ceramic 
crowns. You say that these services are medically necessary. 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 three 
prefabricated abutments (D6056 x3) and three abutment supported porcelain/ceramic crowns (D6058 x3).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endodontic therapy (D3320). 
 
You asked the Plan to pre-approve an endodontic therapy. You say that you need to save the tooth in question 
since you have no molars on either side and need this tooth to help chew your food. You also say that you are 
on a fixed income, and it is a struggle for you to pay your insurance premium. The Plan denied your request. 
The Plan says this service is not a covered expense under your dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
endodontic therapy (D3320).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lower dentures. 
 
You asked the Plan to pre-approve lower dentures. You say that you are unable to eat solid food. The Plan 
denied your request. The Plan says the request exceeds your benefit limitation. 
 
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. The file shows that you last received lower dentures on October 3, 
2019. Dentures are only covered once every 5 years. Based on this information, we decided that the Plan's rules 
for coverage of dentures have not been met. Therefore, we decided that the Plan does not have to pre-approve 
lower dentures.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a root canal therapy (D3330). 
 
You asked the Plan to pre-approve the root canal therapy. You say that you would like this claim to be 
reviewed for coverage. The Plan denied your request. The Plan says this service is not a covered expense under 
the enrollee's dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
root canal therapy (D3330).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and complete lower 
denture (D5120). 
 
You asked the Plan to pre-approve complete dentures. You say that your old dentures are uncomfortable and 
need to be replaced. The Plan denied your request. The Plan says you previously had complete dentures 
provided for both jaws in October of 2020. These services are only covered once every 60 months (5 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 complete or 
partial dentures, once per arch per 60 months. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the documentation supports that the 
dentures are 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) and complete lower denture (D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve three surgical placements of implant bodies: endosteal 
implants (D6010 x3), an abutment supported cast metal crown (D6063), and an implant supported 
porcelain/ceramic crown (D6065). 
 
You asked the Plan to pre-approve the endosteal implants, abutment supported cast metal crown, and implant 
supported porcelain/ceramic crown. 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 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 three 
surgical placements of implant bodies: endosteal implants (D6010 x3), an abutment supported cast metal crown 
(D6063), and an implant supported porcelain/ceramic crown (D6065).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endosteal implants (D6010) provided by a participating 
provider. 
 
You asked the Plan to pre-approve endosteal implants. You say that you need these implants in order to eat. 
The Plan denied your request. The Plan says the requested 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 pre-approve 
endosteal implants (D6010) provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crowns (D2740) for teeth # 24 and 25. 
 
You asked the Plan to pre-approve the dental services. You say that you are in pain. You say that you 
understand this may not be a long term solution. You say that you are willing to pay for your future dental 
services. You also say that this is what your dentist recommended. The Plan denied your request. The Plan says 
the requested crowns are 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 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 crowns are not medically necessary. Our physician reviewer found the documentation 
indicates that teeth # 24 and 25 do not have adequate bone support. As a result, there would not be a reasonable 
prognosis for retention of teeth # 24 and 25. Therefore, the reviewer found that the crowns for teeth # 24 and 25 
are not medically 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 the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve crowns (D2740) for teeth # 24 and 25.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retainer crowns (D6751) for teeth # 28 and 31, and 
pontics (D6241) for teeth # 29 and 30. 
 
You asked the Plan to pre-approve a fixed bridge. You say that you have extreme tooth pain. You say that you 
need your teeth removed and the crown placed. You also say that you do not understand why the services keep 
getting denied. The Plan denied your request. The Plan says the requested fixed bridge is 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 fixed bridge is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
retainer crowns (D6751) for teeth # 28 and 31, and pontics (D6241) for teeth # 29 and 30.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on 
January 15, 2022. 
 
You asked the Plan to waive the copayment for ambulance transportation. You say that you should not be 
responsible for this bill because the advice nurse instructed you to call the ambulance. 
The Plan denied your request. The Plan says coinsurance 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 $200 
copayment per one-way trip.  
 
  You have been asked to pay $200 copayment for ambulance transportation. Ambulance transportation falls 
within the "Ambulance services" 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 
ambulance transportation provided on January 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a porcelain ceramic crown (D2740) and core buildup 
(D2950) for tooth #12. 
 
You asked the Plan to pre-approve a crown and core buildup. You say that these services are necessary. The 
Plan denied your request. The Plan says medical necessity cannot be verified without medical records. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of a crown and core buildup have been met. Specifically, no dental x-rays or medical records were submitted for review. The provider did respond to 
one request for the necessary documentation; however, no records were attached with this reply. Therefore, we 
decided that the Plan does not have to pre-approve a porcelain ceramic crown (D2740) and core buildup 
(D2950) for tooth #12.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve drugs or medicaments dispensed in the office for home 
use (D9630). 
 
You asked the Plan to pre-approve the dental service. You say that this service is necessary. The Plan denied 
your request. The Plan says drugs or medicaments dispensed in the office for home use is not listed as 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested drugs or medicaments 
dispensed in the office for home use is not among those covered under this benefit. The record shows that the 
provider's office confirmed that the code used in this case represents Chlorhexidine pre-rinse. Chlorhexidine 
pre-rinse is not listed as a covered service either and therefore cannot be approved. Therefore, we decided that 
the Plan does not have to pre-approve drugs or medicaments dispensed in the office for home use (D9630).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve upgraded prosthetic components for an above the knee 
prosthesis for a K3 level ambulator including an advanced knee/foot feature coded as L5848, L5930, L5828, 
L5845, L5850, L5981, L5968, L5984. 
 
You asked the Plan to pre-approve the upgraded prosthetic components. You say that the knee is over 4 1/2 
years old and is broken, the microprocessor is not functioning and out of warranty and the foot is under her 
weight limit. The Plan denied your request. The Plan says the records do not support that the enrollee is a K3 
level ambulator and the requested components exceeds the enrollee's needs 
 
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 upgraded prosthetic components. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found in this case, the documentation doesn't support that the member is able 
to ambulate at a K3 level therefore the upgraded prosthetic components including an advanced knee/foot 
feature are not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the upgraded prosthetic components have not been met. Therefore, we decided 
that the Plan does not have to pre-approve upgraded prosthetic components for an above the knee prosthesis for 
a K3 level ambulator including an advanced knee/foot feature coded as L5848, L5930, L5828, L5845, L5850, 
L5981, L5968, L5984.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation with an endodontist. 
 
You asked the Plan to pre-approve the dental service. You say that your gums are bleeding. You say that the 
bones that are coming out are hurting your cheeks on the inside. You say that your gums are very swollen, and 
you do not understand why you were first told it was covered to then be denied. You also say that the pain has 
extended up to your ear. The Plan denied your request. The Plan says dental services performed by an 
endodontist 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 services to be performed by an endodontist are not among those covered under this benefit. Therefore, we decided that the Plan does not 
have to pre-approve a consultation with an endodontist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prefabricated abutments (D6056 x 8) and implant 
supported crowns (D6065 x 8). 
 
You asked the Plan to pre-approve the dental services. You say that you need implants. The Plan denied your 
request. The Plan says dental implants and all associated services 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested prefabricated abutments 
and implant supported crowns are not among those covered under this benefit. Therefore, we decided that the 
Plan does not have to pre-approve prefabricated abutments (D6056 x 8) and implant supported crowns (D6065 
x 8).