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

 
We decided that the Plan does not have to pre-approve an immediate mandibular partial denture - cast metal 
framework with resin denture bases (including retentive/clasping materials, rests and teeth) (D5224). 
 
You asked the Plan to pre-approve an immediate mandibular partial denture - cast metal framework with resin 
denture bases (including retentive/clasping materials, rests and teeth) (D5224). The Plan denied your request. 
The Plan says this service is not covered under the 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 an 
immediate mandibular partial denture - cast metal framework with resin denture bases (including 
retentive/clasping materials, rests and teeth) (D5224).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on June 21, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the 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 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 dental 
services on June 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the two resin-based composites (D2393 x2) provided 
on April 25, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay more for the resin-based composites. You say that you have been going to this same 
dentist for over a year, and gave them your updated card in February 2022, which was accepted with no copay. 
You also say that you were not advised that there was a copay, but were told that your insurance was accepted. 
The Plan denied your request. The Plan says you are responsible for any charged amount above the Plans cost-
sharing amount when your services are received from 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 Plans coverage rules apply in this case. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for the two resin-based composites (D2393 x2) 
provided on April 25, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive oral evaluation - new or established patient 
(D0150) and intraoral - complete series of radiographic images (D0210) provided on May 24, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were not aware that the provider was out-
of-network. The Plan denied your request. The Plan says the dental services were received from an out-of-
network provider therefore the Plan only pays up to a certain amount. The enrollee is responsible for any 
amount greater than what the Plan pays. 
 
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 record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested comprehensive oral evaluation - new or 
established patient and intraoral - complete series of radiographic images are covered under this benefit when 
received from an out-of-network provider. You are responsible for any billed amounts over the Plans cost-
share amount. Therefore, we decided that the Plan does not have to pay for comprehensive oral evaluation - 
new or established patient (D0150) and intraoral - complete series of radiographic images (D0210) provided on 
May 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing services (D4341) 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the charges. 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 May 12, 2020. Therefore, 
we decided that the Plan does not have to pre-approve periodontal scaling and root planing services (D4341)
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87640 billed for date of service November 1, 
2021. 
 
You asked the Plan to pay for procedure code 87640. You say that these services were reported correctly and 
should be paid. The Plan denied your request. The Plan says payment for code 87640 is bundled into payment 
for code 87641. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 87640 
is a column II code to column I code 87641. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 87640 billed for date of service November 1, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for on oral evaluation (D0140) and intraoral radiographic 
image (D0220) provided on July 22, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you did not know th the dentist was an 
out-of-network provider. The Plan denied your request. The Plan says you are responsible for any charged 
amount above the Plans cost-sharing amount when your services are received from 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 Plans coverage rules apply in this case. 
 
  You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for on oral evaluation (D0140) and intraoral 
radiographic image (D0220) provided on July 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite provided on August 15, 2022. 
 
You asked the Plan to pay for the dental services. You say that this service was different from the previous 
service. Therefore, the procedure did not exceed the coverage limits. 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 January 26, 2022. 
Therefore, we decided that the Plan does not have to pay for the resin-based composite provided on August 15, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown porcelain fused to predominantly base metal 
(D2751). 
 
You asked the Plan to pre-approve the dental services. You say that you need this procedure because your 
connecting bridge is going to be removed and you need a crown on the remaining tooth. The Plan denied your 
request. The Plan says that your provider did not provide x-rays of your tooth, therefore the need for a crown 
has not been proven. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the dental services have been met. No 
medical records were provided. Therefore, we decided that the Plan does not have to pre-approve a crown 
porcelain fused to predominantly base metal (D2751).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the guided tissue regeneration (D4266) and the bone 
replacement graft (D7953) for tooth #18 provided on June 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that the provider deemed the dental procedure to be 
medically necessary. The Plan denied your request. The Plan says the denial of payment for these services is 
correct, because the guided tissue regeneration and the bone replacement graft are not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
guided tissue regeneration (D4266) and the bone replacement graft (D7953) for tooth #18 provided on June 7, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) provided 
on August 2, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit under 
your contractual policy. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the service provided is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
comprehensive periodontal evaluation (D0180) provided on August 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cone beam CT image capture with limited field of view less 
than one whole jaw (D0380) provided on June 14, 2022. 
 
You asked the Plan to pay for dental services. You say that you do not think you should pay for the services 
because the provider recommended the services to diagnose an infection. The Plan denied your request. The 
Plan says  this service is not covered under your 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 cone beam CT image 
capture with limited field of view less than one whole jaw (D0380) is not among those covered under this 
benefit. Therefore, we decided that the Plan does not have to pay for cone beam CT image capture with limited 
field of view less than one whole jaw (D0380) provided on June 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the denture (D5140), the placement of implants (D6013), and 
the extractions (D7140) for tooth #18, #20, #21, #22, #23, #24, #25, #26, #27, #28, and #29 provided on July 5, 
2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for the dental 
procedures. The Plan denied your request. The Plan says the extractions were received from an out-of-network 
provider and are not covered by your supplemental benefits. Also, the denial of payment for the denture and 
implants are correct, because they are not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 The record shows you received the extractions from an out-of-network provider. Though the Plan offers a 
dental benefit in excess of Medicare coverage, the extractions are not covered under this benefit when received 
from an out-of-network provider. Also, the denture and implants are not among those covered under this benefit. 
Therefore, we decided that the Plan does not have to pay for the denture (D5140), the placement of implants 
(D6013), and the extractions (D7140) for tooth #18, #20, #21, #22, #23, #24, #25, #26, #27, #28, and #29 
provided on July 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an occlusion analysis - mounted case (D9950), crown - 3/4 
porcelain/ceramic (D2783), and non-intravenous conscious sedation (D9248) provided on June 23, 2022. 
 
You asked the Plan to pay for the occlusion analysis - mounted case (D9950), crown - 3/4 porcelain/ceramic 
(D2783), and non-intravenous conscious sedation (D9248). The Plan denied your request. The Plan says these 
services are not covered under the 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 pay for an 
occlusion analysis - mounted case (D9950), crown - 3/4 porcelain/ceramic (D2783), and non-intravenous 
conscious sedation (D9248) provided on June 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral - periapical first radiographic image (D0220), 
inhalation of nitrous oxide/analgesia, anxiolysis (D9230), limited oral evaluation - problem focused D0140, 
extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140) provided on July 18, 
2022. 
 
You asked the Plan to pay for the intraoral - periapical first radiographic image (D0220), inhalation of nitrous 
oxide/analgesia, anxiolysis (D9230), limited oral evaluation - problem focused D0140, extraction, erupted 
tooth or exposed root (elevation and/or forceps removal) (D7140).  
 You say that you had a cracked molar and could not wait to be seen by an in-network provider. You also say 
that the in-network providers did not have any openings until October. The Plan denied your request. The Plan 
says these services are not covered under the 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 pay for an 
intraoral - periapical first radiographic image (D0220), inhalation of nitrous oxide/analgesia, anxiolysis 
(D9230), limited oral evaluation - problem focused D0140, extraction, erupted tooth or exposed root (elevation 
and/or forceps removal) (D7140) provided on July 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis (D1110) provided on July 22, 2022. 
 
You asked the Plan to pay for the prophylaxis. You say that you feel it is the dentist's responsibility to make 
sure you are not having your cleanings done too soon. You also say that you are on a limited income, and you 
do not feel you should have to pay for this. 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 for the benefit period on date of service 
January 26, 2022, and you were not eligible for the Plan to pay for another cleaning until after July 25, 2022. 
Therefore, we decided that the Plan does not have to pay for the prophylaxis (D1110) provided on July 22, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

Contact the Plan to learn more about how and when your request will be processed.
There are two types of reviews available:
You may have a hearing, which is a meeting with you and the ALJ or Attorney Adjudicator so that you
can talk about your appeal. A hearing is FREE OF CHARGE and can be done over the phone. You are
not required to attend the hearing in person and there is no cost to you for this service.
If you prefer not to participate in the hearing, you may have an on-the-record review. This is also FREE
OF CHARGE and is based on the administrative records and case file sent to OMHA by Maximus.
You can ask for an OMHA review if the amount of money at issue in your appeal meets the hearing
threshold. For hearings requested during 2022, the hearing threshold is $180. This means that the cost of
the service you are requesting or the amount of money you are disputing must exceed $180. This is not the
cost of the hearing or a fee that you have to pay.
To ask for an OMHA review, fill out the "ALJ Hearing Request Form" with this letter and send it to us.
You must send the ALJ Hearing Request Form to us within 60 days of the date of this letter. To have an
on-the-record review, also fill out the "Waiver of Right to an Administrative Law Judge (ALJ) Hearing"
and send it to us.
The Appeal Number is:
1-11762748381
The Appeal Number is:
1-11762748381
Maximus will then send your request form and the case file used to decide your appeal to the OMHA office
in your jurisdiction for review. Once this is done, any further communications regarding your appeal will
come directly from the OMHA office.
You have the right to ask us to vacate (set aside) the dismissal action. If we determine there is good
cause, we will vacate the dismissal and review your appeal request. Your request to vacate this dismissal
must be received by our office within 6 months of the date of this notice. Include a copy of this notice
along with any supporting information with your request.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a filling (D2391) and an x-ray (D0220) for tooth #18 
provided on August 3, 2022. 
 
You asked the Plan to pay for the dental services. You say that you never received an explanation of benefits, 
so you did not know you reached your annual benefit level. The Plan denied your request. The Plan says your 
annual dental benefit for the year 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 annual dental benefit for the year was exhausted on date of service August 3, 2022. On July 20, 
2022, the Plan paid a total of $1,380 towards the yearly annual dental benefit leaving $120 ($1,500 yearly 
benefit - $1,380 paid towards benefit) left of the annual dental benefit. On August 3, 2022, the Plan paid $120 
towards the dental services; therefore, the yearly annual dental benefit was exhausted on the date of service. 
Therefore, we decided that the Plan does not have to pay for a filling (D2391) and an x-ray (D0220) for tooth 
#18 provided on August 3, 2022.