Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve crowns on tooth #7, 8, 9, 10, and 12 (D2751). We also decided 
that the Plan does not have to pre-approve periodontal scaling and root planing in all four quadrants (D4341).  
 
You asked the Plan to pre-approve crowns and periodontal scaling. You say that these services are medically 
necessary. The Plan denied your request. The Plan says that these 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 Plans coverage rules apply in this case. The Plan covers crowns and 
periodontal scaling when the services are medically necessary and reasonable. 
 
We decided that the Plan has to pre-approve crowns on tooth #7, 8, 9, 10, and 12 (D2751).  
 
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 crowns. Our reviewer says that the 
coverage criteria for crowns has been met. Our physician reviewer found that the coronal structure of these 
teeth is severely compromised, and crown restorations are medically reasonable and necessary to provide 
strength and support for adequate masticatory function. 
 
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 crowns have been met. Therefore, we decided that the Plan has to pre-approve 
crowns on tooth #7, 8, 9, 10, and 12 (D2751). 
 
We also decided that the Plan does not have to pre-approve periodontal scaling and root planing in all 
four quadrants (D4341). 
 
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 periodontal scaling and root planing. 
Our reviewer says that the coverage criteria for periodontal scaling has not been met. Our physician reviewer 
found that the documentation did not contain a charting of periodontal pockets and the radiographs did not 
reveal subgingival deposits or bone loss to warrant periodontal scaling and root planing. 
 
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 periodontal scaling have not been met. Therefore, we decided that the Plan does 
not have to pre-approve periodontal scaling and root planing in all four quadrants (D4341). 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the erupted tooth requiring removal of bone and/or 
sectioning of tooth (D7210) provided on December 22, 2021. 
 
You asked the Plan to pay for the dental services. You say that you are requesting reconsideration. You say that 
when your teeth were extracted your dentist and his assistant verified the benefits with the Plan and got 
approval the service would be covered 100%. 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 Plan's 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 December 22, 2021 with 
payment of the extraction (D7140) for tooth #20. Therefore, we decided that the Plan does not have to pay for 
the additional extractions (D7210) provided on December 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 82435, 84132 and 84295 billed for date of 
service August 31, 2021. 
 You asked the Plan to pay for procedure codes 82435, 84132 and 84295. You say that these services are 
supported as billed. The Plan denied your request. The Plan says payment for codes 82435, 84132 and 84295 is 
bundled into payment for code 80051. 
 
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 codes 
82435, 84132 and 84295 are all column II codes to column I code 80051. These services have 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 codes 82435, 84132 and 
84295 billed for date of service August 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone graft on tooth #19 (D6104), dental implant on 
tooth #19 (D6010), and cone beam imaging (D0367). 
 
You asked the Plan to pre-approve the dental services. You say that you disagree with the denial of dental 
services. The Plan denied your request. The Plan says bone grafts (D6104), dental implants (D6010), and cone 
beam imaging (D0367) are not covered by your dental 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. 
 
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 
bone graft on tooth #19 (D6104), dental implant on tooth #19 (D6010), and cone beam imaging (D0367).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bitewing - single radiographic image (D0270) and treatment 
of root canal obstruction; non-surgical access (D3331) on April 21, 2022. 
 
You asked the Plan to pay for bitewing - single radiographic image (D0270) and treatment of root canal 
obstruction; non-surgical access (D3331). You say that you would like to request reconsideration for payment. 
The Plan denied your request. The Plan says the treatment of root canal obstruction; non-surgical access 
(D3331) isn't a covered benefit under the member's plan. A bitewing - single radiographic image (D0270) is a 
covered benefit, however, the enrollee exceeded the frequency limits set in the subscriber agreement on 
January 19, 2022. 
 
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 treatment of root canal obstruction; non-surgical access (D3331) is not among those covered under this benefit. Therefore, we decided that the Plan 
does not have to pay for bitewing - single radiographic image (D0270) and treatment of root canal obstruction; 
non-surgical access (D3331) on April 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services provided on November 29, 2021.
You asked the Plan to pay for these dental services. You say that these services should be covered by the Plan.
The Plan denied your request. The Plan says your benefit for the requested item or service has already been
exhausted. Maximus overturned the Plans denial for a lack of documentation to show this benefit was
exhausted prior to the date of service in question. The Plan requested a reopen and provided the required
documentation.
The Plan is correct in this case. 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 record shows your benefit of $1000 was exhausted on date of service. Therefore, we decided that the Plan
does not have to pay for dental services provided on November 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endodontic therapy (D3310) X 2, prefabricated post and 
core (D2954) X 2, and crown - porcelain/ceramic (D2740) X 1. 
 
You asked the Plan to pre-approve the dental services. You say that you are in dire need to have your front 
teeth repaired. The Plan denied your request. The Plan says there is no coverage for prefabricated post and core 
(D2954) or endodontic therapy (D3310). The Plan also says that the provider already requested the allowed 
frequency of a crown on the appealed claim. 
 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 endodontic therapy and 
prefabricated post and core are not among those covered under this benefit. Though the Plan offers a dental 
benefit in excess of Medicare coverage, certain limitations apply. The record shows your benefit for the crown 
- porcelain/ceramic was exhausted with this pre-service appeal as only one crown is covered per calendar year. 
Therefore, we decided that the Plan does not have to pre-approve endodontic therapy (D3310) X 2, 
prefabricated post and core (D2954) X 2, and crown - porcelain/ceramic (D2740).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation, intraoral x-rays, removal of 
plaque, bitewing x-rays, and resin-based composite (D0150, D0220, D0274, D1110, D2393, D2391) provided 
from April 5, 2022 to April 13, 2022. 
 
You asked the Plan to pay for the comprehensive oral evaluation, intraoral x-rays, removal of plaque, bitewing 
x-rays, and resin-based composite. You say that the services should be covered as you disagree with the denial. 
The Plan denied your request. The Plan says the services denied correctly as they do not fall within your dental 
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 a 
comprehensive oral evaluation, intraoral x-rays, removal of plaque, bitewing x-rays, and resin-based composite 
(D0150, D0220, D0274, D1110, D2393, D2391) provided from April 5, 2022 to April 13, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on May 10, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure codes 14301, 38525, and 14302 are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 14301 is adjacent tissue transfer or rearrangement, any 
area; defect 30.1 sq cm to 60.0 sq cm. The definition of code 38525 is biopsy or excision of lymph node(s); 
open, deep axillary node(s). The definition of code 14302 is adjacent tissue transfer or rearrangement, any area; 
each additional 30.0 sq cm, or part thereof (List separately in addition to code for primary procedure). 
 
 We find that CPT codes 14301, 38525, and 14302 are not supported in the medical record. Specifically, there is 
no documentation of an adjacent tissue transfer or rearrangement of any area, 30.1 sq cm to 60 sq cm, to 
support code 14301. Given that primary code 14301 is not supported, add-on code 14302 is also not supported. 
There is no documentation of a biopsy or excision of the lymph nodes to support code 38525. Based on this 
information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we 
decided that the Plan does not have to pay for the surgical services rendered on May 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the complete mandibular denture (D5120) provided on 
May 5, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you called the Plan and were told that 
dentures were covered 100%. You also say that you were never told about the $1,000 annual maximum and 
you really cannot afford $754. The Plan denied your request. The Plan says your annual dental maximum has 
been met. 
 
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, certain limitations apply. The record 
shows your $1,000 annual dental maximum was exhausted on date of service May 5, 2022. Therefore, we 
decided that the Plan does not have to pay more for the complete mandibular denture (D5120) provided on 
May 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gingival irrigation of the lower right quadrant (D4921). 
 
You asked the Plan to pre-approve the dental services. You say that you want the Plan to reconsider and 
approve the irrigation procedure. The Plan denied your request. The Plan says the requested service was denied 
appropriately. Gingival irrigation is excluded from the Plan's supplemental dental 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-approve 
gingival irrigation of the lower right quadrant (D4921).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oral hygiene instruction (D1330) provided by a participating 
provider on April 13, 2022. 
 
You asked the Plan to pay for oral hygiene instruction. You say that you did not need oral hygiene instructions. 
The Plan denied your request. The Plan says the rendered dental work 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 pay for oral 
hygiene instruction (D1330) provided by a participating provider on April 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nitrous oxide (D9230) and extraction (D7210) on tooth #21-
22 provided on April 5, 2022. 
 
You asked the Plan to pay for nitrous oxide (D9230) and extraction (D7210). You say that you were told the 
services would be covered. The Plan denied your request. The Plan says the requested services are not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for nitrous 
oxide (D9230) and extraction (D7210) on tooth #21-22 provided on April 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided by an 
out-of-network provider on April 26, 2022. 
 
You asked the Plan to pay for the dental services. You say that you had this procedure done without your 
consent. 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 March 4, 2022. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
provided by an out-of-network provider on April 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Crown, porcelain/ceramic (D2740) and Core buildup, 
including any pins when required (D2950) for tooth #10. 
 
You asked the Plan to pre-approve Crown, porcelain/ceramic (D2740) and Core buildup, including any pins 
when required (D2950) for tooth #10. You say that you don't understand why the services are not covered. The 
Plan denied your request. The Plan says the request for tooth #10 exceeds the maximum benefit offered. 
 
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. There is a coverage limitation 
of three every calendar year; one per tooth every five calendar years. 
 
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 
Crown, porcelain/ceramic (D2740) and Core buildup, including any pins when required (D2950) for tooth #10.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service August 28, 
2021.  You asked the Plan to pay for procedure code 99053. You say that the medical records support the claim as 
originally billed and the claim should be processed toward payment. The Plan denied your request. The Plan 
says procedure codes 99285 has been overturned and procedure code 99053 is considered bundled and not 
separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99053 billed for date of service August 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a filling (D2391) provided on April 19, 2022. 
 
You asked the Plan to pay for a filling. You say that the service should be covered. The Plan denied your 
request. The Plan says the service at issue 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 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 a filling 
(D2391) provided on April 19, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the resin-based composite (D2331) provided on April 27, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would face financial hardship if required to 
pay for this service. The Plan denied your request. The Plan says the maximum allowed amount, in this case, is 
the charge for the less expensive alternate procedure. 
 
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. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not include medical records in their case file. Without medical 
records, the Plan did not substantiate their decision to only cover one-surface resin as opposed the two-surface 
resin that you received. The contract clearly says that the alternate treatment must produce a professionally 
satisfactory result. The Plan has neither explained, nor supported with evidence, their assessment that the one-
surface resin composite was sufficient. Therefore, we decided that the Plan has to pay for the resin-based 
composite (D2331) provided on April 27, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on April 
25, 2022. 
 
You asked the Plan to pay for the dental services. You say that the dental office performed the x-ray due to a 
filling coming out of the tooth. You say that they noted the dentist wanted to verify the correct way to replace 
the filling to prevent it from coming out again. 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 November 3, 2020. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
provided on April 25, 2022.