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

 
We decided that the Plan does not have to pre-approve the outpatient implantation of LinQ Sacroiliac Joint 
Stabilization System 
 
You asked the Plan to pre-approve the LinQ Sacroiliac Joint Stabilization System. You say that the surgery is 
medically necessary, and the surgery is safe and effective. The Plan denied your request. The Plan says  the 
surgery is not medically necessary. The Plan says the surgery is considered experimental. 
 
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 LinQ Sacroiliac Joint Stabilization 
System. Our reviewer says that the requested surgery is not considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee was being treated for sacroiliitis. The enrollee presented 
status post left SI joint injection with approximately 80% relief, and it is starting to wear off some. The detailed documentation is not evident regarding imaging or radiographic evidence supporting a significant sacroiliitis 
pathology. There is no clear history of SI joint pain onset or failure of conservative treatment directed to the SI 
joint. Multiple other plausible pain generators including at the lumbosacral spine and or hips are evident. There 
are limited large-scale, long-term references showing the safety and efficacy of the requested surgery in this 
clinical setting. There is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception. Therefore, the requested LinQ Sacroiliac Joint Stabilization 
System 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 LinQ Sacroiliac Joint Stabilization System have not been met. Therefore, 
we decided that the Plan does not have to pre-approve the outpatient implantation of LinQ Sacroiliac Joint 
Stabilization System
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a prefabricated crown (D2931) provided on January 17, 
2023. 
 
You asked the Plan to pay for the dental service. You say that you were not aware that the crown would not be 
covered, and you would like the Plan to pay 50% of it for being out-of-network. The Plan denied your request. 
The Plan says the denial of payment for this service is correct, because the prefabricated crown is 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 item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
prefabricated crown (D2931) provided on January 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for gas mileage for the enrollee's doctor' appointments 
provided from January 3, 2022, to December 27,2022. 
 
You asked the Plan to reimburse for gas mileage for the enrollee's doctor' appointments. You say that you are 
eligible for reimbursement for mileage. The Plan denied your request. The Plan says you did not make advance 
arrangements through the Plan. 
 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 routine transportation when arrangements are set up in advance with the Plan.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to reimburse for gas mileage for the enrollee's doctor' appointments provided from January 
3, 2022, to December 27,2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a core buildup, including any pins when required 
(D2950). 
 
You asked the Plan to pre-approve this item. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the requested dental item 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 item is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a core buildup, 
including any pins when required (D2950).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for polycarbonate lenses (V2784) provided March 16, 2023.  
You asked the Plan to pay for polycarbonate lenses (V2784). You say that you were told that the frames and 
lens would be covered The Plan denied your request. The Plan says polycarbonate lenses are not a covered 
benefit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers one pair of standard frames and standard lenses. 
 
We looked at the file and the Plan's rules. The Plan rules say that they cover one pair of standard frames. The 
Plan rules also say that standard lenses are single vision, lined bifocal, and line trifocal lenses. The Plan rules 
also say polycarbonate lenses are exuded from this benefit. Based on this information, we decided that the 
Plan's rules for coverage of polycarbonate lenses (V2784) have not been met. Therefore, we decided that the 
Plan does not have to pay for polycarbonate lenses (V2784) provided March 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the precision attachment, by report (D5862). 
 
You asked the Plan to pre-approve the precision attachment, by report (D5862). You say that you have never 
been able to eat with the dentures in. You also say that this has caused you to lose weight and experience health 
problems related to poor nutrition.  The Plan denied your request. The Plan says D5862 as it is not in the list of 
covered dental codes. 
 
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 the precision 
attachment, by report (D5862).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve reline complete maxillary denture (D5730). 
 
You asked the Plan to pre-approve reline complete maxillary denture. You say that this should be covered. The 
Plan denied your request. The Plan says this is not 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
reline complete maxillary denture (D5730).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service January 30, 
2023. 
 You asked the Plan to pay for procedure code 70450. You say that 70450 should be covered because it was not 
bundled with another procedure code. The Plan denied your request. The Plan says payment for code 70450 is 
bundled into payment for code 70496. 
 
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, we have confirmed that code 70450 
is a column II code to column I code 70496. The column I code was billed by another physician of the same 
specialty under the same billing group. This claim has not been billed with an appropriate modifier to bypass 
the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 70450 billed for date of service January 30, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the minimally invasive percutaneous left sacroiliac (SI) 
fusion with placement of the LinQ SI Joint Stabilization System 
 
You asked the Plan to pre-approve the SI fusion surgery. You say that  the service is medically necessary and 
safe and effective. The Plan denied your request. The Plan says the SI fusion is not medically necessary. The 
Plan contract says the LinQ Joint Stabilization System is experimental, and more research is needed to show 
safety and efficacy. 
 
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 SI fusion surgery. Our reviewer 
says that the requested SI fusion surgery not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was being treated for sacroiliitis and presented with having a 90% relief overall for the first couple of days with the right SI joint injection then the pain returned. However, detailed 
documentation is not evident regarding imaging or radiographic evidence supporting a significant sacroiliitis 
pathology. There is no clear history of SI joint pain onset or failure of conservative treatment directed to the 
right SI joint other than injection on June 12, 2023. There are multiple other plausible pain generators. There 
are limited large-scale, long-term references showing the safety and efficacy of the requested surgery in this 
clinical setting. There is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception. Therefore, the requested LinQ SI Joint Stabilization System 
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 SI fusion surgery have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the minimally invasive percutaneous left sacroiliac (SI) fusion with placement of 
the LinQ SI Joint Stabilization System
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom fabricated abutment  includes placement 
tooth #10 (D6057), and abutment supported porcelain fused to metal crown tooth #10 (high noble metal) 
(D6059). 
 
You asked the Plan to pre-approve the dental services represented by codes D0657 and D6059. You say that 
piece #10 is a custom made post that is part of a piece of 5 teeth that go together to be attached to 3 posts that 
go together. You also say that you would like to use your remainder of $2,080 for the tooth # 10 service. 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 services was exhausted on date of service June 7, 2023. Therefore, we 
decided that the Plan does not have to pre-approve a custom fabricated abutment  includes placement tooth 
#10 (D6057), and abutment supported porcelain fused to metal crown tooth #10 (high noble metal) (D6059).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bone replacement graft for ridge preservation (D7953) 
provided on May 8, 2023. 
 
You asked the Plan to pay for bone replacement graft for ridge preservation (D7953). You say that this 
procedure is regarded as a medical benefit. The Plan denied your request. The Plan says the service is not a 
benefit of the members benefits 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 bone 
replacement graft for ridge preservation (D7953) provided on May 8, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI).  
 
You asked the Plan to pre-approve SSBCI benefits. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says the criteria for eligibility have not been met.  
 
  The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an 
eligible condition that meets all the required criteria. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pontic - porcelain/ceramic (#26, #28) (D6245) and 
retainer crown - porcelain/ceramic (#27) (D6740). 
 
You asked the Plan to pre-approve 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. Therefore, we decided that the Plan does 
not have to pre-approve pontic - porcelain/ceramic (#26, #28) (D6245) and retainer crown - porcelain/ceramic 
(#27) (D6740).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI).  
 
You asked the Plan to pre-approve SSBCI benefits. You say that you were denied but you forgot t add that you 
also deal with paranoid schizophrenia. The Plan denied your request. The Plan says the criteria for eligibility 
have not been met.  
 
  The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an 
eligible condition that meets all the required criteria. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve overdenture  complete mandibular (D5865). 
 
You asked the Plan to pre-approve overdenture  complete mandibular. You say that this should be covered. 
The Plan denied your request. The Plan says this is not 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
overdenture  complete mandibular (D5865).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of implant body, endosteal (D6010 x 
4) and custom fabricated abutment, includes placement (D6057 x 4). 
 
You asked the Plan to pre-approve 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. Therefore, we decided that the Plan does 
not have to pre-approve surgical placement of implant body, endosteal (D6010 x 4) and custom fabricated 
abutment, includes placement (D6057 x 4).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the bone marrow aspirate. 
 
You asked the Plan to pre-approve the bone marrow aspirate. You say that the service is medically necessary. 
The Plan denied your request. The Plan says the bone marrow aspirate is not medically necessary. The Plan 
says a detailed description of the manufacturer, type of allograft and specific allograft name is needed, but was 
not supplied. 
 
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 bone marrow aspirate. Our reviewer 
says that the requested surgery is 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 with neurogenic 
claudication. There is no specific indication provided to support the request for bone marrow aspirate for the approved surgery. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use 
of bone marrow aspirate for this enrollees medical condition as discussed above. There is no compelling 
rationale or extenuating circumstances noted to support the medical necessity of this request as an exception. 
Therefore, the requested bone marrow aspirate 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 bone marrow aspirate have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the bone marrow aspirate.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the periodontal scaling and root planing (D4341) on all 
4 quadrants. 
 
You asked the Plan to pre-approve the dental services. You say that the requested dental services are medically 
necessary because your gums are open, and it can lead to an infection. 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 the periodontal scaling and root planing (D4341) for all 4 quadrants on June 2, 2021, 
and July, 6, 2021; therefore, your benefit for the requested items or services was exhausted on the dates of 
service of June 2, 2021, and July 6, 2021. Therefore, we decided that the Plan does not have to pre-approve the 
periodontal scaling and root planing (D4341) on all 4 quadrants.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 45380 billed for date of service December 
23, 2022.  
 You asked the Plan to pay for procedure code 45380. You say that code 45380 was billed correctly and should 
be paid. The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 45380 is 1 unit. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 45380 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 45380 billed for date of service December 23, 2022.