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

 
We decided that the Plan does not have to pre-approve implantation of the Minuteman G3R interspinous device 
at the L4-L5 level (22612, 22840).  
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the requested 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 this service. Our reviewer says that the 
requested service is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee was being treated for spinal stenosis of the lumbar region with neurogenic claudication. 
He presented with ongoing low back pain extending bilaterally across the belt line. He reports overall that his 
pain continues to be moderate to severe but hasnt changed much at this time.   
There is no new numbness, tingling, weakness, or radicular pain. The exam reveals pain and limited 
thoracolumbar range of motion. There is lumbar spinal stenosis present. However, current evidence-based 
medical guidelines and peer-reviewed literature do not fully support the interspinous fusion device procedure 
over the gold standard of lumbar fusion. There is a lack of large-volume, long-term peer-reviewed outcome 
studies to support the use of this device for this enrollees medical condition. According to the Food and Drug 
Administration (FDA), The HA Minuteman G3-R MIS Fusion Plate is a posterior, non-pedicle supplemental 
fixation device, intended for use at a single level in the non-cervical spine (T1-S1). The HA Minuteman G3-R 
MIS Fusion Plate is intended for use with bone graft material and is not intended for stand-alone use. 
 
In addition, fusion indications within guidelines/literature for (existing or potential intraoperative) instability 
have not been documented and/or met in this case. In addition, there are multiple alternate pain generators 
plausibly significantly contributing to the clinical condition that have not been fully documented as having 
been excluded and/or ruled out. No compelling rationale is presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. Therefore, the requested implantation of the 
Minuteman G3R interspinous device at the L4-5 level 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 this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve implantation of the Minuteman G3R interspinous device at the L4-L5 level (22612, 
22840).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the fluoride gel carrier (D5986). 
 
You asked the Plan to pre-approve the fluoride gel carrier. You say that you feel this should be covered due to 
you are having radiation therapy and this will help protect your teeth. The Plan denied your request. The Plan 
says fluoride gel carrier is not listed as a covered service under your dental 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
fluoride gel carrier (D5986).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mandibular partial denture - cast metal framework 
with resin denture bases (D5214). 
 
You asked the Plan to pre-approve the mandibular partial denture. You say that your dentures do not fit and the 
dentist will not take them back. You also say that your new dentist submitted a request for a new set of 
dentures and you need them in order to do daily living tasks such as eating. 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 January 3, 2022. Therefore, we decided that the Plan does not have to pre-approve a mandibular partial denture - cast metal 
framework with resin denture bases (D5214).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment provided from March 20, 
2023, to July 16, 2023. 
 
You asked the Plan to pay for the durable medical equipment. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the provider is not enrolled in 
the Medicare program. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the durable medical equipment provided 
from March 20, 2023, to July 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost sharing for a complete denture-maxillary (D5110) 
and a mandibular partial denture (D5214) provided on May 26, 2022. 
 
You asked the Plan to reduce the cost sharing for the dental services. You say that you are requesting 
reconsideration of the cost share applied or a refund from the provider. The Plan denied your request. The Plan 
says the claim processed correctly per your plan benefit for dental services. 
 
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 have been asked to pay a 50% 
coinsurance of the allowed amount after paying a $50 deductible. 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 reduce the 
cost sharing for a complete denture-maxillary (D5110) and a mandibular partial denture (D5214) provided on 
May 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics.  
 
You asked the Plan to pre-approve foot orthotics. You say that you have a herniated disk on your back and you 
can barely stand, and the custom inserts are medically necessary. The Plan denied your request. The Plan says 
this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
  Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 power wheelchair (K0843) with tilt/recline, 
seating and upgraded electronics. 
 
You asked the Plan to pre-approve a group 2 power wheelchair (K0843) with tilt/recline, seating and upgraded 
electronics. You say that the requested group 2 power wheelchair (K0843) with tilt/recline, seating and 
upgraded electronics is medically necessary.  The Plan denied your request. The Plan says the enrollee does not 
meet criteria for a group 2 power wheelchair (K0843) with tilt/recline, seating and upgraded electronics.  
 
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 a group 2 power wheelchair (K0843) 
with tilt/recline, seating and upgraded electronics. Our reviewer says that the enrollee does not meet criteria for 
a group 2 power wheelchair (K0843) with tilt/recline, seating and upgraded electronics.  Our physician 
reviewer found the enrollee has chronic back pain and chronic obstructive pulmonary disease (COPD). He is 
able to walk short distances. The enrollee does not have high risk for skin breakdown, use a catheter 
intermittently, have spasticity or require an alternative means of managing power drive. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a group 2 power wheelchair (K0843) with tilt/recline, seating and upgraded 
electronics have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 2 
power wheelchair (K0843) with tilt/recline, seating and upgraded electronics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periapical each additional radiographic image (D0230) 
provided on July 18, 2023. 
 
You asked the Plan to pay for the dental services. You say that this 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 requested item or service was exhausted on date of service July 18, 2023. Therefore, 
we decided that the Plan does not have to pay for periapical each additional radiographic image (D0230) 
provided on July 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the implantation of a subperiosteal implant (21246). 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the requested service is not a covered benefit.  
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The service you are asking the Plan to pre-approve involves the care, treatment, filling, removal or replacement 
of the enrollees teeth or the structures directly supporting the enrollees teeth. This is a dental service that is 
not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve the 
implantation of a subperiosteal implant (21246).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation miles. 
 You asked the Plan to pre-approve the additional miles. You say that you need the additional miles to attend an 
appointment so that the surgeon can sign you off on getting fitted for your prosthetic leg. You also say that you 
are an amputee who can't drive yourself and have no other means of transportation.  The Plan denied your 
request. The Plan says you are requesting an additional 32 miles for a total of 82 miles and your benefit only 
allows 50 miles. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 50 miles trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to pre-approve 32 
additional routine transportation miles for an appointment. The record shows the shortest mileage from your 
house to the office, combining/avoiding tolls, highways, and ferries is a total of 81.4 miles, which is 31.4 miles 
over your allowed benefit. Based on this information, we decided that you have exhausted the Plan maximum 
benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve 
additional routine transportation miles.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve comprehensive orthodontic treatment of the adult 
dentition (D8090). 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the requested service is not covered under the 
supplemental dental 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 service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
comprehensive orthodontic treatment of the adult dentition (D8090).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the guided tissue regeneration (D4266), the sinus 
augmentation (D7951), the bone replacement graft (D7953), the anesthesia (D9239 and D9243), a consultation 
(D9310), and the therapeutic parenteral drugs (D9612). 
 
You asked the Plan to pre-approve the dental services. You say that you have a failed implant, and it needs to 
be removed or you run a risk of it getting infected. The Plan denied your request. The Plan says the denial of 
authorization for these services is correct, because the guided tissue regeneration, the sinus augmentation, the 
bone replacement graft, the anesthesia, a consultation, and the therapeutic parenteral drugs are not covered by 
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 the 
guided tissue regeneration (D4266), the sinus augmentation (D7951), the bone replacement graft (D7953), the 
anesthesia (D9239 and D9243), a consultation (D9310), and the therapeutic parenteral drugs (D9612).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Minuteman procedure at the L3-5 level (20930, 
22612, 22840). 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the requested 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 this service. Our reviewer says that the 
requested service is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee was being treated for spinal stenosis of the lumbar region without neurogenic 
claudication. He presented with back pain that is mostly axial but can radiate across into his hips and the back 
of his thighs and sides of his thighs. The pain is aching. Over the last few years, it has been worsening.  
However, current evidence-based medical guidelines and peer-reviewed literature do not fully support the 
interspinous fusion device procedure over the gold standard of lumbar fusion. There is a lack of large-
volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollees medical 
condition. According to the Food and Drug Administration (FDA), The HA Minuteman G3-R MIS Fusion 
Plate is a posterior, non-pedicle supplemental fixation device, intended for use at a single level in the non-
cervical spine (T1-S1). The HA Minuteman G3-R MIS Fusion Plate is intended for use with bone graft 
material and is not intended for stand-alone use. 
 
In addition, fusion indications within guidelines/literature for (existing or potential intraoperative) instability 
have not been documented and/or met in this case. In addition, there are multiple alternate pain generators 
plausibly significantly contributing to the clinical condition that have not been fully documented as having 
been excluded and/or ruled out. No compelling rationale is presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. Therefore, the requested Minuteman procedure at 
the L3-5 level 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 this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Minuteman procedure at the L3-5 level (20930, 22612, 22840).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a partial lower 
denture (D5212). 
 
You asked the Plan to pre-approve the dental services. You say that you went to a second dentist to get new 
dentures because your other dentures were hurting you. The Plan denied your request. The Plan says your 
benefit for the requested items or services 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 the Plan paid for a complete upper denture (D5110) and a partial lower denture (D5214) on December 3, 
2021; therefore, your benefit for the requested items or services was exhausted on the date of service of 
December 3, 2021. Therefore, we decided that the Plan does not have to pre-approve a complete upper denture 
(D5110) and a partial lower denture (D5212).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a kyphoplasty. 
 
You asked the Plan to pre-approve the kyphoplasty. You say that the request is supported by imaging of a 
fracture, the failure of conservative treatments, documented height loss and treatment for osteoporosis. The 
Plan denied your request. The Plan says the criteria for coverage 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 the kyphoplasty. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that detailed documentation is not evident regarding the worsening of pain. Additionally, there 
is no documentation of a progression of the body height loss, greater than 25% vertebral body height loss, 
kyphotic deformity, or a severe impact on daily activities. Moreover, there is magnetic resonance imaging 
(MRI) corroboration of other plausible causes of pain. Therefore, the enrollee does not meet LCD coverage 
criteria. 
 
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 kyphoplasty have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a kyphoplasty.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ophthalmic biometry (92136) provided on 
September 12, 2023. 
 
You asked the Plan to waive the copayment for ophthalmic biometry (92136). You say that you paid the 
copayment of $35. You also say that two weeks later you got a bill for an additional $5. The Plan denied your 
request. The Plan says this cost sharing was charged correctly. 
 
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 a $5 
copayment for diagnostic lab services and diagnostic procedures and tests. 
 
You have been asked to pay a $5 copayment for ophthalmic biometry (92136). This item/service falls within 
the diagnostic lab services and diagnostic procedures and tests 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 ophthalmic biometry (92136) provided on September 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services with an OON provider. 
 
You asked the Plan to pre-approve the dental services. You say that this is medically necessary. The Plan 
denied your request. The Plan says dental services from an out-of-network provider 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. 
 
You are requesting 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 pre-approve dental 
services with an OON provider.