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

 
We decided that the Plan does not have to pay for prophylaxis (D1110) and bitewing x-rays (D0274) provided 
on April 21, 2022. 
 
You asked the Plan to pay for prophylaxis and x-rays. You say that you should not be responsible for checking 
to see if the provider was in-network. You also say that if you were aware the provider was out-of-network you 
would not have had the services done. The Plan denied your request. The Plan says these services are not 
covered when received by an 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 
among those covered under this benefit when received by an out-of-network provider. Therefore, we decided 
that the Plan does not have to pay for prophylaxis (D1110) and bitewing x-rays (D0274) provided on April 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture and 
interpretation (D0366), surgical placement of implant body: endosteal implant (D6010), bone replacement graft 
for ridge preservation (D7953), and radiographic/surgical implant index (D6190) provided on February 14, 2022. 
 
You asked the Plan to pay for the cone beam CT capture and interpretation, endosteal implant, bone 
replacement graft, and radiographic/surgical implant index. The Plan denied your request. The Plan says these 
procedures are not covered under your 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 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the cone 
beam computed tomography (CT) capture and interpretation (D0366), surgical placement of implant body: 
endosteal implant (D6010), bone replacement graft for ridge preservation (D7953), and radiographic/surgical 
implant index (D6190) provided on February 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental implants on tooth #30 and 31 (D6010), fabricated 
abutment on tooth #30 and 31 (D6057), abutment supported crowns on tooth #30 and 31 (D6058), and surgical 
implant indexing (D6190). 
 
You asked the Plan to pre-approve implants, abutments, crowns, and surgical indexing. You say that the 
enrollee is not able to receive a bridge due to the length of span. The Plan denied your request. The Plan says 
dental implants (D6010), fabricated abutment (D6057), abutment supported crowns (D6058), and surgical 
implant indexing (D6190) are not covered by the Plan's routine 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 pre-approve 
dental implants on tooth #30 and 31 (D6010), fabricated abutment on tooth #30 and 31 (D6057), abutment 
supported crowns on tooth #30 and 31 (D6058), and surgical implant indexing (D6190).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on March 17, 2022. 
 
You asked the Plan to pay for an evaluation. You say that the dentist never told you that they were out-of-
network. The Plan denied your request. The Plan says a limited oral evaluation (D0140) is covered once a year 
when received by an in-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. 
 
 We looked at this case file, the Plan's rules, and Medicare rules. The record shows the Plan paid for a limited 
oral evaluation provided on February 16, 2022; therefore, the benefit for a limited oral evaluation has been 
exhausted. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) 
provided on March 17, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric services. 
 
You asked the Plan to pre-approve inpatient psychiatric services. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric services. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found based upon review 
of the records provided, this enrollee does not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of June 28, 2022 forward and could have been treated in a lesser 
restrictive setting. He was not showing any suicidal or homicidal ideation, auditory or visual hallucinations, 
delusions and was not showing any behaviors or aggression. He was being cooperative and compliant while not 
showing any acute threats to safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient psychiatric services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implant/abutment supported denture (D6110), guided 
tissue regeneration (D4267), surgical implants (D6010), precision abutments (D5862) and prefabricated 
abutments (D6056). 
 
You asked the Plan to pre-approve dental services. You say that these services are necessary. The Plan denied 
your request. The Plan says these services are not covered by your 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 an implant/abutment supported denture 
(D6110), guided tissue regeneration (D4267), surgical implants (D6010), precision abutments (D5862) and 
prefabricated abutments (D6056).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal exam (D0180) provided on April 28, 2022, 
by the out of network dentist. 
 
You asked the Plan to pay for the dental service. You say that you were not advised the dentist was out of 
network. You say that when you called the plan to apply for reimbursement you were never advised the dentist 
was out of network. You also say that had you known the dentist was out of network you would have changed 
to another dentist. The Plan denied your request. The Plan says the claim processed correctly. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the periodontal exam is not among 
those covered under this benefit when received out of network. Therefore, we decided that the Plan does not 
have to pay for the periodontal exam (D0180) provided on April 28, 2022, by the out of network dentist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), intraoral imaging 
(D0220), and bitewings (D0274), provided by an out-of-network provider on February 1, 2022. 
 
You asked the Plan to pay for a limited oral evaluation, intraoral imaging, and bitewings. You say that these 
services should be paid. The Plan denied your request. The Plan says the services provided have been 
processed correctly. 
 
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 one limited 
oral evaluation per year. 
 
We looked at the file and Medicare rules. Evidence was provided to show that D0140 was previously provided 
on January 20, 2022. Based on this information, we decided that the Plan's rules for coverage of a limited oral 
evaluation have not been met. Intraoral imaging and bitewings have been processed and paid according to the 
out-of-network benefit rules. Therefore, we decided that the Plan does not have to pay for a limited oral 
evaluation (D0140). The Plan has paid intraoral imaging (D0220), and bitewings (D0274), according to the 
out-of-network benefit rules provided by an out-of-network provider on February 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endosteal implants (D6010), prefabricated abutments 
(D6056), and implant supported porcelain/ceramic crowns (D6065). 
 
You asked the Plan to pre-approve endosteal implants, prefabricated abutments, and implant supported 
porcelain/ceramic crowns. You say that you need implants in at least 3 teeth to support your dentures. The Plan 
denied your request. The Plan says these services are not covered under your benefit 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 
endosteal implants (D6010), prefabricated abutments (D6056), and implant supported porcelain/ceramic 
crowns (D6065).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral - periapical first radiographic image (D0220), 
intraoral - periapical each additional radiographic image (D0230), and 2D oral/facial photographic image 
obtained intra-orally or extra-orally (D0350) provided December 9, 2021. 
 
You asked the Plan to pay for the first and additional periapical x-rays and 2D oral/facial photographs. You say 
that the examination felt excessive, and the dentist tried to pressure you into signing papers. The Plan denied 
your request. The Plan says these services are not covered under your 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 
intraoral - periapical first radiographic image (D0220), intraoral - periapical each additional radiographic image 
(D0230), and 2D oral/facial photographic image obtained intra-orally or extra-orally (D0350) provided 
December 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a two dimensional (2D) oral/facial photographic image 
(D0350), diagnostic casts (D0470), interim crown (D2799), and gingival irrigation (D4921). 
 
You asked the Plan to pre-approve a 2D oral/facial photographic image, diagnostic casts, interim crown, and 
gingival irrigation. The Plan denied your request. The Plan says these services are not covered under the 
enrollee's benefit 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 a two dimensional (2D) oral/facial 
photographic image (D0350), diagnostic casts (D0470), interim crown (D2799), and gingival irrigation 
(D4921).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on March 16, 2022. 
 
You asked the Plan to pay for the panoramic x-ray. You say that you needed a jaw x-ray not only for a prompt 
diagnosis, but also as a cost savings. The Plan denied your request. The Plan says this service exceeds the 
frequency limitation in your benefit 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, panoramic x-ray (D0330) is limited to 
one procedure every three plan years. The record shows that you received a panoramic x-ray (D0330) on June 
29, 2020, and your panoramic x-ray (D0330) benefit has been exhausted. Therefore, we decided that the Plan 
does not have to pay for the panoramic x-ray (D0330) provided on March 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an out-of-network provider on 
February 17, 2022. 
 
You asked the Plan to pay for dental services. You say that the Plan paid for most of your work the year prior. 
The Plan denied your request. The Plan says services provided by an out-of-network provider 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. The Plan covers covered 
dental services when the services are provided by a participating provider. 
 
We looked at the file and Medicare rules. The rendering dentist is out-of-network. Based on this information, 
we decided that the Plan's rules for coverage of dental services have not been met. Therefore, we decided that 
the Plan does not have to pay for dental services provided by an out-of-network provider on February 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prophylaxis (D1110) provided by an out-of-network provider 
on February 28, 2022. 
 
You asked the Plan to pay for prophylaxis. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says services must be provided by a participating 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. The Plan covers prophylaxis 
when the services are medically necessary and reasonable.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of prophylaxis have not been met.  
 
Therefore, we decided that the Plan does not have to pay for prophylaxis (D1110) provided by an out-of-
network provider on February 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral imaging (D0220 and D0230) provided by a 
participating provider February 10, 2022. 
 
You asked the Plan to pay for intraoral imaging. You say that you do not understand why this is not covered. 
You say that this was a routine dental exam. The Plan denied your request. The Plan says the rendered 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 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 intraoral 
imaging (D0220 and D0230) provided by a participating provider on February 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing (D4341), gingival 
irrigation (D4921), and oral drugs (D9630), provided by a participating provider on July 9, 2021, to July 19, 2021. 
 
You asked the Plan to pay for periodontal scaling and root planing, gingival irrigation, and oral drugs. You say 
that you would like the Plan to pay for this. The Plan denied your request. The Plan says these services have 
been processed correctly. 
 
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 one 
periodontal scaling and root planning per quadrant every three years. The Plan does not cover a gingival 
irrigation or oral drugs. 
 
We looked at the file and Medicare rules. Evidence was provided to show that D4341 was previously provided 
on May 23, 2019. Based on this information, we decided that the Plan's rules for coverage of periodontal 
scaling and root planing have not been met. The Plan does not cover D4921 or D9630. Therefore, we decided 
that the Plan does not have to pay for periodontal scaling and root planing (D4341), gingival irrigation (D4921), 
and oral drugs (D9630), provided by a participating provider on July 9, 2021, to July 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a guided tissue regeneration (D4266) and bone 
replacement graft for ridge preservation (D7953). 
 
You asked the Plan to pre-approve the guided tissue regeneration and bone replacement graft. The Plan denied 
your request. The Plan says these services are not covered under the enrollee's benefit 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 a 
guided tissue regeneration (D4266) and bone replacement graft for ridge preservation (D7953).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a maxillary complete denture (D5110) provided on March 
16, 2022. 
 
You asked the Plan to pay for the dentures. You say that you disagree with the denial of dental services. The 
Plan denied your request. The Plan says a maxillary complete denture (D5110) is 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 pay for a 
maxillary complete denture (D5110) provided on March 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140), and bone replacement 
graft (D7953) provided on February 14, 2022. 
 
You asked the Plan to pay for the dental services. You say that your bridge broke along with teeth attached to 
the bridge. You say that you were surprised to find out the bone grafts were not covered as they were 
performed on the same day as an extraction. You also say that these services should be covered. The Plan 
denied your request. The Plan says the services are not listed as 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 limited oral evaluation and bone 
replacement graft are not among those covered under this benefit. Therefore, we decided that the Plan does not 
have to pay for the limited oral evaluation (D0140), and bone replacement graft (D7953) provided on February 
14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite (D2393), and an occlusal adjustment 
(D9951), provided by an out-of-network provider on February 1, 2022, to February 3, 2022. 
 
You asked the Plan to pay for a resin-based composite and an occlusal adjustment. You say that you would like 
the Plan to pay for this. The Plan denied your request. The Plan says the denied 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 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 resin-
based composite (D2393), and an occlusal adjustment (D9951), provided by an out-of-network provider on 
February 1, 2022, to February 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sterile gauze rendered on October 22, 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 code A6219 is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code A6219 has a status indicator of P on the Physician Fee Schedule. This means that 
CPT code A6219 is not separately payable. 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 sterile 
gauze rendered on October 22, 2021.