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

 
We decided that the Plan does not have to pre-approve precision attachments (D5862). 
 
You asked the Plan to pre-approve precision attachments. You say that you need this dental work. The Plan 
denied your request. The Plan says the requested dental service has been correctly denied. 
 
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 
precision attachments (D5862).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical procedure for isolation of tooth with rubber 
dam (D3910). 
 
You asked the Plan to pre-approve a dental surgical procedure. You say that you need a root canal, and this 
tooth is causing a lot of pain. The Plan denied your request. The Plan says the requested dental service has been 
denied 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. 
 
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 
surgical procedure for isolation of tooth with rubber dam (D3910).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bilateral sacroiliac joint fusion. 
 
You asked the Plan to pre-approve bilateral sacroiliac joint fusion. You say that the services are necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
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 bilateral sacroiliac joint fusion. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is no compelling rationale presented or extenuating circumstances 
noted to support the medical necessity of this request as an exception. Therefore, the requested bilateral 
sacroiliac joint fusion, in this case, is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bilateral sacroiliac joint fusion have not been met. Therefore, we decided that 
the Plan does not have to pre-approve bilateral sacroiliac joint fusion.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a crown (D2740) provided on November 16, 2022. 
 
You asked the Plan to pay more for the dental service. You say that you $1,800 dental services allowance has 
not been met. The Plan denied your request. The Plan says your maximum dental benefit for the year 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. On January 
4, 2022, the Plan paid $793 for dental services. On April 7, 2022, the Plan paid $64 for dental services. On July 
8, 2022, the Plan paid $138 for dental services. On November 16, 2022, the Plan paid $805 for dental services. 
For the year of 2022 the Plan paid $1,800 ($793 paid + $64 paid + $138 paid + $805 paid) for dental services.  
The record shows your annual dental benefit for the year was exhausted on the date of service of November 16, 
2022. Therefore, we decided that the Plan does not have to pay more for a crown (D2740) provided on 
November 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture (D5225). 
 
You asked the Plan to pre-approve the dental services. You say that you lost your dentures. The Plan denied 
your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service February 16, 2022. 
Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture (D5225).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan of the 
brain. 
 
You asked the Plan to pre-approve the PET scan. You say that the enrollee is suspected of having degenerative 
central nervous system disease. The Plan denied your request. The Plan says the records do not show the 
enrollee has been diagnosed with AD and FTD. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the PET scan. Our reviewer says that 
the PET scan of the brain is not medically necessary. Our physician reviewer found that the records provided 
for review suggested that the enrollee had a neurodegenerative process superimposed on Parkinson's disease. 
However, the records did not support that the member met diagnostic criteria for both AD and FTD. Rather 
there was a suggestion of AD vs Lewy body dementia. Given that the records did not support the base 
requirement of the NCD for performance/coverage of this service, it would not be said to meet Medicare 
criteria for coverage at this time. 
 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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan of the brain.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 an Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. Therefore, the requested Intracept intraosseous 
basivertebral nerve ablation at L1, in this case, is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the dance classes (A9270) provided from 
January 1, 2022, through December 31, 2022. 
 
You asked the Plan to issue reimbursement for these services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says these services are 
not a covered benefit. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
 The Plans rules for coverage of gym benefits have not been met because the dance classes provided are not 
covered under this benefit. Therefore, we decided that the Plan does not have to issue reimbursement for the 
dance classes (A9270) provided from January 1, 2022, through December 31, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgery provided on October 03, 2022. 
 
You asked the Plan to pay for surgery. You say that you are requesting reconsideration. The Plan denied your 
request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for surgery provided on 
October 03, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for an oral exam provided on November 14, 2022. 
 
You asked the Plan to pay for the dental services. You say that you needed this exam. The Plan denied your 
request. The Plan says that your benefit for the requested item or service has already been exhausted. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. There is no evidence showing your benefit for the requested item or service was previously 
exhausted. Therefore, we decided that the Plan has to pay for an oral exam provided on November 14, 2022.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on October 07, 2022. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for office visit provided on 
October 07, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for endoscopy provided on September 20, 2022. 
 
You asked the Plan to pay for endoscopy. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for endoscopy provided on 
September 20, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar interbody instrumented fusion surgery coded as 
22853, 63052, 63053, 20936, 20936, 22612, 22614, 22630, 22632, 22633 and 22840. 
 
You asked the Plan to pre-approve the fusion surgery. You say that you are appealing the surgery authorization 
denial. The physician has clarified on attached clinical note why the enrollee needs the part of the surgery that 
was denied The Plan denied your request. The Plan says the requested fusion surgery is 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 the fusion surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was being treated for spinal stenosis of the lumbar region without 
neurogenic claudication. The enrollee presented with low back pain that radiates to the right buttock and right 
calf. However, dynamic flexion/extension films are not provided in order to potentially assess the amount of 
movement (instability) at the requested surgical level. Detailed documentation is not evident regarding 
potential impending/inevitable temporary intra-operative instability. There is no compelling rationale presented 
or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, 
the requested lumbar interbody fusion at L3-4 and L4-5, in this case, is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the fusion surgery have not been met. Therefore, we decided that the Plan does 
not have to pre-approve lumbar interbody instrumented fusion surgery coded as 22853, 63052, 63053, 20936, 
20936, 22612, 22614, 22630, 22632, 22633 and 22840.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lift chair, tax, and deliver/setup (E0627, A9901, S9999), 
provided on August 25, 2022. 
 
You asked the Plan to pay for the lift chair, tax, and deliver/setup. You say that the item was medically 
necessary. The Plan denied your request. The Plan says the chair, tax, and delivery/setup are not covered 
services. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pay for the lift chair, tax, and deliver/setup (E0627, A9901, S9999), 
provided on August 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the upgraded electronics (E2311, E2313, E2377). 
 
You asked the Plan to pre-approve the upgraded electronics. You say that the requested items are medically 
necessary. The Plan denied your request. The Plan says that the upgraded electronics are not medically 
necessary. The Plan follows Medicare rules. Medicare rules say that a power seat elevation feature (E2300) is not covered 
because it is not primarily medical in nature. The rules say that a harness (E2313) describes all of the wires, 
fuse boxes, fuses, circuits, switches, etc. that are required for the operation of an expandable controller. It also 
includes all the necessary fasteners, connectors, and mounting hardware. The rules also say that for power 
wheelchairs which are capable of being upgraded to an expandable controller (K0862), E2377 is used if an 
expandable controller is provided at the time of initial issue.  
 
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 electronics. Our reviewer 
says that the coverage criteria has not been met. Our physician reviewer found that the enrollee has been a full-
time power wheelchair user for several years. The enrollee can transfer with assistance out of her wheelchair. 
The medical records document the enrollee has 3+ strength in the upper extremities. The documentation does 
not support that the upgraded electronics are 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 electronics have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the upgraded electronics (E2311, E2313, E2377).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the power seat elevation (E2300) and attendant control 
(E2331). 
 
You asked the Plan to pre-approve the power seat elevation and attendant control. You say that the requested 
items are medically necessary. The Plan denied your request. The Plan says that the power seat evaluation is 
not primarily medical in nature. The Plan also says that the attendant control is not covered when a user-
operated control is requested. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. Medicare rules also say that if an attendant control (E2331) is provided in addition to a 
beneficiary-operated drive control system, it will be denied as non-covered. 
 
The power seat elevation does not serve a purpose that is primarily medical in nature and cannot be covered. 
An attendant control is not covered in addition to the beneficiary-operated drive control. Therefore, we decided 
that the Plan does not have to pre-approve the power seat elevation (E2300) and attendant control (E2331).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the computer-assisted musculoskeletal surgical 
navigational orthopedic procedure (0055T). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the service is 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 the service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is limited published, large-scale, long-term peer-reviewed literature that shows this 
request to be an effective and/or safe treatment for the noted pathology. The clinical benefits (including 
ultimate outcomes of functional improvement and pain reduction) with computer navigation are not fully literature evident. There is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception. Therefore, the requested computer-assisted musculoskeletal 
surgical navigational orthopedic procedure for left hip surgery, in this case, is not medically reasonable or 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the computer-assisted musculoskeletal surgical navigational orthopedic procedure 
(0055T).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Medtronic Infuse BMP allograft (20930). 
 
You asked the Plan to pre-approve Medtronic Infuse BMP allograft. You say that the requested services are a 
medical necessity for the enrollee. The Plan denied your request. The Plan says the requested services are 
experimental/investigational. 
 
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 Medtronic Infuse BMP allograft. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found that there is limited published, large-scale, long-term, peer-reviewed literature 
that shows the requested allograft to be an effective and/or safe treatment for the enrollee's pathology. Further 
studies are needed to demonstrate the request allograft has beneficial outcomes compared with conventional treatment. There is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Medtronic Infuse BMP allograft have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Medtronic Infuse BMP allograft (20930).