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

We decided that the Plan does not have to pre-approve upper and lower dentures.
You asked the Plan to pre-approve dentures. You say that you accidentally threw your dentures away, and have trouble eating food. The Plan denied your request. The Plan says the denial of authorization for these dentures is correct, because you received a set of these dentures on May 16, 2016 and therefore the benefit for dentures is exhausted at this time.
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 1 set of complete maxillary and mandibular dentures every 60 months. We looked at the file, the Plan's rules, and Medicare rules. You received dentures within the past 60 months, therefore the Plan's benefit for dentures is exhausted at this time. 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 upper and lower dentures.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental implants (D6066).
You asked the Plan to pre-approve dental implants (D6066). You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says they have approved the requested dental crown with code D2750. The Plan says implants with dental code D6066 are not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested dental implants (D6066) are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve dental implants (D6066).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core build up (D2950) for teeth # 11 and 12.
You asked the Plan to pre-approve the core build up for teeth # 11 and 12. The Plan denied your request. The
Plan says core build up 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 Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, core build up is not among those
covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core build up
(D2950) for teeth # 11 and 12.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services (D5120, D9222, D9223, D9610, D9310).
You asked the Plan to pre-approve the services. You say that you are being treated unfairly, as you went to another dental provider in 2018 and they didn't perform the services correctly. The Plan denied your request. The Plan says this is not a covered benefit.
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. A complete denture service (D5120) was performed on November 27, 2018. This is less than five years prior to this request. Dentures are only covered once every five years. Additionally, the remaining services (D9222, D9223, D9610, D9310) are not listed as covered benefits in your contract. Therefore, we decided that the Plan does not have to pre-approve dental services (D5120, D9222, D9223, D9610, D9310).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an implant placement (D6010) for teeth # 22 and 27, prefabricated abutments (D6056) for teeth # 22 and 27, and a modification of a removable prosthesis following implant surgery (D5875).
You asked the Plan to pre-approve the dental services. You say that there is bone loss so the implant is a necessary procedure. The Plan denied your request. The Plan says the requested dental services are not listed as covered services.
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 dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an implant placement (D6010) for teeth # 22 and 27, prefabricated abutments (D6056) for teeth # 22 and 27, and a modification of a removable prosthesis following implant surgery (D5875).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided an OON provider, on December 3, 2019.
You asked the Plan to pay for the dental services. You say that you understand that you did not go to a contracted dental provider. The Plan denied your request. The Plan says this provider is not a contracted plan provider. The Plan also says that you knowingly received dental services from this out-of-network provider.
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 covered when they are received out-of-network. Therefore, we decided that the Plan does not have to pay for the dental services provided an OON provider, on December 3, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core buildup including any pins (D2950) on tooth #6.
You asked the Plan to pre-approve core Buildup. You say that the records should support the necessity of the services. The Plan denied your request. The Plan says this request exceeds the benefit limit.
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. This service is covered once every 60 months, per tooth. Records show that the enrollee received this same service, D2950 on tooth 6 on August 26, 2019. The enrollee will not be eligible for this until August 27, 2024. 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 core buildup including any pins (D2950) on tooth #6.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental crowns (D2954).
You asked the Plan to pre-approve dental crowns (D2954). You say that you would like the plan to reconsider
their denial. The Plan denied your request. The Plan says the dental 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 Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested dental crowns (D2954)
are not among those covered under this benefit. Therefore, we decided that the Plan does not have to preapprove
dental crowns (D2954).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary partial denture with a flexible base (D5225).
You asked the Plan to pre-approve the dental service. You say that you are allergic to metal. You also say that you cannot wear the partial denture that was approved. The Plan denied your request. The Plan says a maxillary partial denture with flexible base 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 Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the partial denture with a flexible base is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture with a flexible base (D5225).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an upper partial denture with a flexible base (D5225).
You asked the Plan to pre-approve the dental item. You say that once your upper jaw tooth is removed, you will have no support for the partial denture that you already have. You say that you will not be able to chew. You also say that you will only have 3 teeth on your upper right side. The Plan denied your request. The Plan says a partial denture with a flexible base 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 Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested partial denture with a flexible base is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an upper partial denture with a flexible base (D5225).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an occlusal guard (D9940).
You asked the Plan to pre-approve the dental item. You say that your dentist advised that you need an occlusal
guard for your various dental issues. The Plan denied your request. The Plan says occlusal guards are not a
covered item.
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 dental item is not among
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an occlusal
guard (D9940).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal maintenance (D4910), surgical bone reshaping (D4260) for all 4 quadrants, and periodontal scaling and root planing (D4341) for the upper right, lower left, and lower right quadrants.
You asked the Plan to pre-approve the surgical bone reshaping for all 4 quadrants and the periodontal scaling and root planing for the upper right, lower left, and lower right quadrants. You say that you do not want any surgery. You say that you need the deep cleaning to be done and to be approved. You also say that your gums are bleeding and your mouth is very tender and sore. The Plan denied your request. The Plan says the requested dental services 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 Plan's coverage rules apply in this case. The Plan covers the surgical bone reshaping for all 4 quadrants and the periodontal scaling and root planing for the upper right, lower left, and lower right quadrants. 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 surgical bone reshaping for all 4 quadrants and the periodontal scaling and root planing for the upper right, lower left, and lower right quadrants. Our reviewer says that the criteria for coverage has not be met. Our physician reviewer found the documentation provided did not support the criteria for coverage of the requested dental services. 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 surgical bone reshaping for all 4 quadrants and the periodontal scaling and root planing for the upper right, lower left, and lower right quadrants. have not been met. Therefore, we decided that the Plan does not have to pre-approve periodontal maintenance (D4910), surgical bone reshaping (D4260) for all 4 quadrants, and periodontal scaling and root planing (D4341) for the upper right, lower left, and lower right quadrants.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the surgical extraction (D7210), and the consultation (D9310) provided on September 19, 2019.

You asked the Plan to reimburse you for the dental services. You say that your wisdom teeth were causing you excruciating pain. You also say that there was not a nearby dentist to where you lived. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that the dental services you received are not covered when you receive the services out of network. The Plan also says the services could have been provided in network.

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 dental services you received are not covered when you receive them out of network. Therefore, we decided that the Plan does not have to reimburse you for the surgical extraction (D7210), and the consultation (D9310) provided on September 19, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a porcelain with gold crown (D2752) for tooth # 3.
You asked the Plan to pre-approve the dental service. You say that you want to have your teeth be finished. You say that the procedure was denied because bridges are only covered to replace 1 upper area anterior tooth and there cannot be any missing posterior teeth in the arch. The Plan denied your request. The Plan says crowns are covered once every 60 months per patient, per tooth. The Plan also says that the frequency limit has been reached.
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 and crowns are a covered service, the frequency limit has been reached. The record shows the Plan paid for a crown that you received for tooth # 3 on February 22, 2019. Therefore, we decided that the Plan does not have to pre-approve a porcelain with gold crown (D2752) for tooth # 3.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown (D2740) and core buildup (D2950) provided on 
May 7, 2020. 
 
You asked the Plan to pay for the crown (D2740) and core buildup (D2950). You say that your dental coverage 
does not say what your $500 per year benefit is for. You say that you thought you were covered up to $500. 
The Plan denied your request. The Plan says the services are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the crown 
(D2740) and core buildup (D2950) provided on May 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Core Build Up (D2950).You asked the Plan to pre-approvethe Core Build Up. You say that the core build up is medically necessary.The Plan denied your request. The Plan says the requested service is not a covered benefit.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-approvea Core Build Up (D2950).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110).
You asked the Plan to pre-approve the complete maxillary denture. You say that you need these dentures because your old dentures broke. The Plan denied your request. The Plan says this service exceeds the benefit allowance.
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, one of a complete maxillary denture (D5110) or an immediate maxillary denture (D5130) are covered per 60 months. The record shows that you received a complete maxillary denture on August 11, 2015 and your maxillary denture benefit is now exhausted until after August 11, 2020. Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture (D5110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core build up (D2950 x 6).
You asked the Plan to pre-approve the core build up. You say that the enrollee's teeth # 7, 8, 9, and 10 are severely broken down and carious with undermining of the fractured incisal edges. You say that teeth # 4 and 30 have existing fillings with recurrent carries. You also say that teeth # 5 and 2 need to be surgically removed due to the coronal portion of the tooth. The Plan denied your request. The Plan says core build up 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 Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested core build up is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core build up (D2950 x 6).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower denture (D5120).
You asked the Plan to pre-approve the dental items. You say that when your teeth were removed, the provider harmed the bone. You say that it is impossible for you to eat. You also say that you need your bone to be lowered and for your dentures to fit well. The Plan denied your request. The Plan says the frequency limit for dentures of once every 60 months has been reached.
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 frequency limit for dentures has been reached. The record shows that you last received a complete upper denture and an immediate lower denture on June 12, 2019. Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower denture (D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341), periodontal procedures (D4999), gingival irrigation (D4921), and resin-based composites (D2392, D2391, D2330, D2331, and D2393).
You asked the Plan to pre-approve periodontal scaling and root planing, periodontal procedures, gingival irrigation, and resin-based composites. You say that these services should be covered as it is necessary to have them done before you get knee surgery. The Plan denied your request. The Plan says these dental services are not covered by Medicare or the 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 periodontal scaling and root planing (D4341), periodontal procedures (D4999), gingival irrigation (D4921), and resin-based composites (D2392, D2391, D2330, D2331, and D2393).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the maxillary partial denture and extraction provided by an OON dentist on September 3, 2019.
You asked the Plan to pay for the maxillary partial denture and extraction. You say that you were told several times that you would be reimbursed for these services. The Plan denied your request. The Plan says you self-referred to an out-of-network provider. The Plan also says that non-emergency services provided by an out-of-network provider are not available with this dental 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 covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the maxillary partial denture and extraction provided by an OON dentist on September 3, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two custom fabricated abutments - includes placement
(D6057) and two abutment supported porcelain fused to metal crowns (D6059).
You asked the Plan to pre-approve the custom fabricated abutments (D6057) and abutment supported porcelain
fused to metal crowns (D6059). You say that you need the crowns in order to be able to eat properly. You also
say that you are unable to eat, and it is causing you a lack of nutrition. The Plan denied your request. The Plan
says these services are not covered benefits.
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 two
custom fabricated abutments - includes placement (D6057) and two abutment supported porcelain fused to
metal crowns (D6059).