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

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on 
October 26, 2021. 
You asked the Plan to pay for comprehensive oral evaluation. You say that multiple plan representative 
provided wrong information regarding the provider's network status. You also say that payment should be 
made for these services as a result. The Plan denied your request. The Plan says the claim was 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and comprehensive oral evaluation is 
listed as covered, the frequency limit of one every 3 years has been exceeded. The record shows that the Plan 
paid for a comprehensive oral evaluation that you received on July 19, 2019. Additionally, you may be billed 
by the out of network provider for any amount greater than the payment made by the Plan to the provider. 
Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) 
provided on October 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical extraction (D7210), general anesthesia (D9222, 
D9223), and unspecified adjunctive procedures (D9999) provided on October 21, 2021. 
 
You asked the Plan to pay for the dental services. You say that these services were necessary and should be 
covered. The Plan denied your request. The Plan says the provider in this case has chosen to opt-out of 
Medicare and does not receive Medicare funds. Based on your contract with the Plan, these services are 
excluded from coverage and are not eligible for payment. 
 
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. Your contract with the Plan 
says you may see any licensed dental provider who accepts Medicare patients in the United States and has not 
opted out of Original Medicare.  If you use a provider that has opted out of Medicare, you will not receive reimbursement. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, items or services received from 
providers who do not participate in Medicare are not covered under this benefit. Documentation shows that this 
provider has chosen to opt out of Medicare. Therefore, we decided that the Plan does not have to pay for the 
surgical extraction (D7210), general anesthesia (D9222, D9223), and unspecified adjunctive procedures 
(D9999) provided on October 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical placement of implant body: endosteal implant 
(D6010). 
 
You asked the Plan to pre-approve the endosteal implant. You say that you cannot pay for this procedure 
yourself and your teeth hurt. The Plan denied your request. The Plan says this service is 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 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 surgical placement of implant body: 
endosteal implant (D6010).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110), and a complete 
mandibular denture (D5120) provided by a participating provider. 
 
You asked the Plan to pre-approve a complete maxillary and mandibular denture. You say that you thought it 
had been long enough. The Plan denied your request. The Plan says the benefit limit for dentures 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. The Plan covers a complete 
maxillary and mandibular denture when the services are medically necessary and reasonable.  
 
We looked at the file and Medicare rules. Evidence was provided to show that dentures were provided on 
September 13, 2017. Based on this information, we decided that the Plan's rules for coverage of a complete 
maxillary and mandibular denture have not been met. Therefore, we decided that the Plan does not have to pre-
approve a complete maxillary denture (D5110), and a complete mandibular denture (D5120) provided by a 
participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a resin-based composite (D2332) provided 
by a participating provider on December 2, 2021. 
 
You asked the Plan to waive the coinsurance for a resin-based composite. You say that you thought this would 
be fully covered. The Plan denied your request. The Plan says the correct coinsurance has been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for dental services/restorative dental services.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for a resin-based composite. The total 
allowed amount is $133. The total amount you are being asked to pay is $26.60 ($133 x 20% = $26.60). A 
resin-based composite falls within the dental services/restorative dental services benefit category.  This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the coinsurance for a resin-based composite (D2332) provided by a 
participating provider on December 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve biologic materials to aid in soft and osseous tissue 
regeneration, per site (D4265) for teeth # 6, 7, 8, 9, 10, and 11. 
 
You asked the Plan to pre-approve the dental services. You say that you need the urgent services. You say that 
you are in pain. You also say that your health is in danger. The Plan denied your request. The Plan says 
biologic materials to aid in soft and osseous tissue regeneration 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve biologic 
materials to aid in soft and osseous tissue regeneration, per site (D4265) for teeth # 6, 7, 8, 9, 10, and 11.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an addition amount for the fixed partial denture provided on 
October 4, 2021. 
 
You asked the Plan to pay an addition amount for the fixed partial denture. You say that the services you 
received were an emergency. You say that the payment should not have been limited to your dental plan 
maximum. The Plan denied your request. The Plan says the benefit maximum of $2,000 has 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 and the fixed partial denture is a 
covered service, the benefit maximum of $2,000 has been exhausted in the processing of this claim. The record 
shows that the Plan paid $10 for dental services received on June 10, 2021, $451.50 for services received on 
July 28, 2021, and $1,448.50. $100 + $451.50 + $1,448.50 = $2,000. Although there is a 40% coinsurance for a 
fixed partial denture, the benefit maximum has been exceeded. Therefore, we decided that the Plan does not 
have to pay an addition amount for the fixed partial denture provided on October 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and 
repair resin partial denture base (D5612) provided on November 3, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the problem focused limited oral evaluation and repair resin partial denture base. 
You say that your insurance agent changed your Plan trying to get you more help on your dental work. You 
also say that you were not told your doctor would not be in-network under the new insurance plan. The Plan 
denied your request. The Plan says services performed by an OON provider are not covered because your 
healthcare plan does not have OON 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, you are responsible for 100% of the 
cost for dental services rendered by an OON provider. Therefore, we decided that the Plan does not have to pay 
for the problem focused limited oral evaluation (D0140) and repair resin partial denture base (D5612) provided 
on November 3, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the consultation (D9310) provided on November 30, 2021. 
 
You asked the Plan to pay for the dental service. You say that this visit was necessary due to your periodontal 
disease. You say that it is difficult to limit your visits to 1 consultation. You also say that you cannot afford to 
pay the $100. The Plan denied your request. The Plan says consultation is not a covered dental service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the consultation is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the consultation 
(D9310) provided on November 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewing x-rays (D0272), initial periapical x-ray 
(D0220), and additional periapical x-ray (D0230) provided on December 20, 2021. 
 
You asked the Plan to pay for the dental services. You say that the x-rays are part of the cleaning process and 
should be covered. The Plan denied your request. The Plan says bitewing x-ray is not a covered service. The 
Plan says that periapical x-rays are not covered either. 
 
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 bitewing x-ray and periapical x-
rays are not among those covered under this benefit.  Therefore, we decided that the Plan does not have to pay for the bitewing x-rays (D0272), initial periapical x-ray (D0220), and additional periapical x-ray (D0230) provided on December 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for porcelain/ceramic crown (D2740), core buildups (D2950), 
porcelain/ceramic pontic (D6245) and retainer crown (D6740) provided on September 29, 2021. 
 
You asked the Plan to pay for the dental services. You say that you were approved for these services, and you 
did not expect to have a bill for this care. The Plan denied your request. The Plan says you have met and 
exceeded your annual $4,000 limit for dental care. You are responsible for any charges that exceed this annual 
allowance. 
 
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 up to $4,000 
for covered dental services each year. After this annual maximum is exhausted, any remaining charges are your 
responsibility. Though the Plan offers a dental benefit in excess of Medicare coverage, items or services that exceed the Plans 
annual allowance are not covered under this benefit. The record shows that the Plan has paid the full annual 
allowance amount for your dental care in 2021. Therefore, we decided that the Plan does not have to pay for 
porcelain/ceramic crown (D2740), core buildups (D2950), porcelain/ceramic pontic (D6245) and retainer 
crown (D6740) provided on September 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for urgently needed services provided on 
October 23, 2021. 
 
You asked the Plan to waive the copayment for urgently needed services. You say that you should not owe a 
copayment for these services. The Plan denied your request. The Plan says the claims were processed correctly 
and you are being charged the correct amount. 
 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 
copayment for urgently needed services.  
 
You have been asked to pay a $30 copayment for urgently needed services. Urgently needed services fall 
within the urgently needed services benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
urgently needed services provided on October 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), panoramic x-ray 
(D0330), prophylaxis (D1110), and preventive procedure (D1999) provided on October 20, 2020 by a provider 
who has opted out of Medicare. 
 
You asked the Plan to pay for the periodic oral evaluation, panoramic x-ray, prophylaxis, and preventive 
procedure. You say that you were unaware that your dentist did not accept Medicare or was a non-participant. 
You also say that this was never disclosed to you prior to receiving the denial. The Plan denied your request. 
The Plan says you received these services from a provider who chose not to receive Medicare funds. The Plan 
also says that you made no contacts to the Plan in regard to your cost share or provider questions prior to 
receiving these 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 items or services are not 
covered when they are received by a provider who has opted out of Medicare. Therefore, we decided that the 
Plan does not have to pay for the periodic oral evaluation (D0120), panoramic x-ray (D0330), prophylaxis 
(D1110), and preventive procedure (D1999) provided on October 20, 2020 by a provider who has opted out of 
Medicare.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on October 29, 2021. 
 
You asked the Plan to waive the copayment for an office visit. You say that you do not feel that the visit should 
have a copayment because you just received education on diabetes management. The Plan denied your request. 
The Plan says the claims were processed correctly, and you are being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 
copayment for primary care provider visits.  
 
The medical records show that you received services beyond diabetes management on October 29, 2021. 
Therefore, you are responsible to pay the $10 copayment.  
 
You have been asked to pay a $10 copayment for an office visit. An office visit falls within the 
physician/practitioner services, including doctor's office visits benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for an office visit provided on October 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve drugs or medicaments dispensed in the office for home 
use (D9630 x5). 
 
You asked the Plan to pre-approve the drugs or medicaments. The Plan denied your request. The Plan says this 
service is not covered under the enrollee's benefit package. 
 
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 
drugs or medicaments dispensed in the office for home use (D9630 x5).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical extraction (D7210) provided on November 30, 2021. 
 
You asked the Plan to pay for the surgical extraction. You say that you went into your regular dentist thinking 
it was a simple extraction you needed. You also say that upon further inspection by your dentist, they 
determined that a surgical removal necessary. The Plan denied your request. The Plan says your contract does 
not cover this 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
surgical extraction (D7210) provided on November 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the provisional splinting - intracoronal (D4320) provided 
October 22, 2021. 
 
You asked the Plan to pay for the provisional splinting. You say that this procedure was done to save your 
tooth. The Plan denied your request. The Plan says this service is 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 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 the 
provisional splinting - intracoronal (D4320) provided October 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic x-ray (D0330), periodic oral exam (D0120), 
bone replacement graft (D7953), deep sedation/general anesthesia (D9223) and extractions (D7140) provided 
on June 29, 2021. 
 
You asked the Plan to pay for the dental services. You say that you were told you would be reimbursed for this 
care by a Plan representative. The Plan denied your request. The Plan says these services were performed by a 
provider who has chosen to opt-out of Original Medicare. Therefore, these services are not eligible for payment 
per your contract. 
 
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 Plans contract states that 
you may see any licensed dental provider who accepts Medicare patients in the United States and has not opted out of Original Medicare. If you use a provider that has opted out of Medicare, you will not receive 
reimbursement. 
 
We looked at the file and the Plan's rules. The provider in this case does not participate in Original Medicare 
and is on the Centers for Medicare and Medicaid Services opt-out provider list. Based on this information, we 
decided that the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that 
the Plan does not have to pay for the panoramic x-ray (D0330), periodic oral exam (D0120), bone replacement 
graft (D7953), deep sedation/general anesthesia (D9223) and extractions (D7140) provided on June 29, 2021.  
 
Your complaint about potential misinformation from a Plan representative is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial lower denture (D5214). 
 
You asked the Plan to pre-approve the dental item. You say that you are missing teeth. You say that you need 
this to help maintain eating habits. The Plan denied your request. The Plan says partial denture is 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 partial denture is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
partial lower denture (D5214).