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

 
We decided that the Plan does not have to pay for crowns (D2740) and core buildups (D2950) for tooth #4, #6, 
#7, #8, #9, #10, #11, #19, #20, and #29. 
 
You asked the Plan to pay for the dental services. You say that it is necessary to approve the dental procedures. 
The Plan denied your request. The Plan says the denial of authorization for these services is correct, because 
medical necessity could not be established by the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
  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. The 
provider did not submit any additional documents for review. The x-rays that were submitted were not clear 
and medical necessity cannot be established without medical documentation. Therefore, we decided that the 
Plan does not have to pay for crowns (D2740) and core buildups (D2950) for tooth #4, #6, #7, #8, #9, #10, #11, 
#19, #20, and #29.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam CT capture (D0364) and a limited oral 
evaluation (D0140) provided by a participating provider on July 13, 2022. 
 
You asked the Plan to pay for a cone beam CT capture and a limited oral evaluation. You say that these 
services were medically necessary. The Plan denied your request. The Plan says the rendered dental 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, D0364 is not among those covered 
under this benefit. The benefit limit for D0140 was exhausted on June 24, 2022. Therefore, we decided that the 
Plan does not have to pay for a cone beam CT capture (D0364) and a limited oral evaluation (D0140) provided 
by a participating provider on July 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for periodontal maintenance (D4910) 
provided by a participating provider on May 24, 2022. 
 
You asked the Plan to waive the coinsurance for periodontal maintenance. You say that you are expecting to be 
reimbursed for this. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 70% 
coinsurance for Periodontal Maintenance/in-network.  
 
You have been asked to pay a 70% coinsurance of the allowed amount for periodontal maintenance. The total 
amount is $122. The total amount you are being asked to pay is $85.40 ($122 x 70% = $85.40). This 
item/service falls within the Periodontal Maintenance/in-network 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 periodontal maintenance (D4910) provided by a participating provider on May 24, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan has paid the full $1,500 dental benefit for services provided on August 2, 2022. 
 
You asked the Plan to pay for the dental services. You say that you should not have to pay anything for the 
services provided. 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 August 2, 2022. 
Therefore, we decided that the Plan has paid the full $1,500 dental benefit for services provided on August 2, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral radiographic images (D0210) provided on July 
20, 2022. 
 
You asked the Plan to pay for the dental services. You say that the provider told you that the x-rays were 
needed. 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 the date of service of July 20, 2022. 
Therefore, we decided that the Plan does not have to pay for the intraoral radiographic images (D0210) 
provided on July 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extraction, erupted tooth requiring removal of bone and/or 
sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) provided on August 25, 
2022. 
 
You asked the Plan to pay for the dental services. You say that you had two teeth extracted and they both 
should be covered. 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 August 25, 2022. The 
Plan paid for extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140), which is 
the one extraction per lifetime. Therefore, we decided that the Plan does not have to pay for extraction, erupted 
tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if 
indicated (D7210) provided on August 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for osseous surgery (D4261) for teeth numbers 09, 16, 17, 24, 
25, 32, and biologic materials to aid in soft and osseous tissue regeneration (D4265) for tooth number 18 
provided on May 11, 2022. 
 
You asked the Plan to pay for osseous surgery (D4261) for teeth numbers 09, 16, 17, 24, 25, 32, and biologic 
materials to aid in soft and osseous tissue regeneration (D4265) for tooth number 18. You say that you were 
told that the claim was going to be resubmitted with the proper codes and would be covered completely, except 
for $52 that you would be responsible for. The Plan denied your request. The Plan says the service or item in 
question is not covered under the Member's contract under any normal circumstances. 
 
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 osseous 
surgery (D4261) for teeth numbers 09, 16, 17, 24, 25, 32, and biologic materials to aid in soft and osseous 
tissue regeneration (D4265) for tooth number 18 provided on May 11, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve periodontal scaling and root planing - four or more teeth per 
quadrant (D4341). 
 
You asked the Plan to pre-approve the dental services. You say that the requested services is needed. The Plan 
denied your request. The Plan says that your benefit for the requested item or service has already been 
exhausted. 
 
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.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. There is no evidence showing your benefit for the requested item or service was previously 
exhausted. Also, the Explanation of Coverage (EOC) and Dental booklet provided do not list limitations for the 
service at issue. Therefore, we decided that the Plan has to pre-approve periodontal scaling and root planing - 
four or more teeth per quadrant (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 oral photographic images (D0350) and panoramic 
radiographic imaging (D0330) provided by a participating provider on August 11, 2022. 
 
You asked the Plan to pay for oral photographic images and panoramic radiographic imaging. You say that you 
would like the Plan to give you a one-time courtesy for these services. 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, D0350 is not among those covered 
under this benefit. The benefit for D0330 was exhausted on August 11, 2022. Therefore, we decided that the 
Plan does not have to pay for oral photographic images (D0350) and panoramic radiographic imaging (D0330) 
provided by a participating provider on August 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periapical additional radiographic images (D0230) 
provided on August 17, 2022. 
 
You asked the Plan to pay for the dental service. You say that you would like the dental service paid. 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 the date of service of August 17, 2022. 
Therefore, we decided that the Plan does not have to pay for the periapical additional radiographic images 
(D0230) provided on August 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periapical radiographic image (D0230) and to pay more for 
a crown (D2740) for tooth #4 provided on May 10, 2022. 
 
You asked the Plan to pay for the dental services. You say that the providers office overcharged you for the 
dental services. The Plan denied your request. The Plan says your benefit for the periapical radiographic image 
has already been exhausted and the proper coinsurance payment was made for the crown. 
 
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 periapical radiographic image was exhausted on the date of service of May 10, 2022. 
The total allowed amount for the crown was $698 and a coinsurance charge of $488.60 ($698 total amount x 
70% coinsurance). Therefore, we decided that the Plan does not have to pay for a periapical radiographic image 
(D0230) and to pay more for a crown (D2740) for tooth #4 provided on May 10, 2022.  
 Your complaint about the provider charges on a credit card 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 cone beam computed tomography (CT) capture and 
interpretation with field of view of both jaws; with or without cranium (D0367) and a bone replacement graft 
for ridge preservation-per site (D7953). 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says the requested services are not covered under the 
enrollees 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 requested services are not among 
those covered under this benefit.  Therefore, we decided that the Plan does not have to pre-approve cone beam computed tomography (CT) 
capture and interpretation with field of view of both jaws; with or without cranium (D0367) and a bone 
replacement graft for ridge preservation-per site (D7953).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral evaluation (D0120), bitewings (D0274), the 
prophylaxis (D1110), and the fluoride varnish (D1206) provided on August 2, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were never informed that the provider was 
an out-of-network provider. The Plan denied your request. The Plan says the dental services were received 
from an out-of-network provider and are not covered by your supplemental 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. 
 
  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 items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for the oral evaluation (D0120), bitewings (D0274), the prophylaxis (D1110), and the fluoride varnish 
(D1206) provided on August 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a post-operative office visit (D0171) provided on August 23, 
2022. 
 
You asked the Plan to pay for a post-operative office visit (D0171). You say that this was for dental issues. The 
Plan denied your request. The Plan says the service in question is not covered under the member's contract 
under any normal circumstances. 
 
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 post-
operative office visit (D0171) provided on August 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gingivectomy (D4210) and the removal of torus 
mandibularis (D7473) for tooth #9 and #10. 
 
You asked the Plan to pre-approve the dental services. You say that you would like to appeal the denied dental 
services. The Plan denied your request. The Plan says the denial of authorization for these services is correct, 
because gingivectomy and the removal of torus mandibularis is 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 pre-approve 
gingivectomy (D4210) and the removal of torus mandibularis (D7473) for tooth #9 and #10.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral - periapical each additional radiographic image 
(D0230) provided on August 8, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told all the services you received 
would be covered. 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. This benefit includes the 
requested intraoral - periapical each additional radiographic image but is limited to one procedure code per 
calendar year. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested intraoral - periapical each additional radiographic image was exhausted on 
date of service August 8, 2022. You had two procedure codes performed on the same day, the Plan paid for 
intraoral - periapical first radiographic image (D0220) on August 8, 2022. This counts as your one procedure 
code per calendar year. Therefore, we decided that the Plan does not have to pay for intraoral - periapical each 
additional radiographic image (D0230) provided on August 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endodontic therapy (D3320) to be provided by an out-
of-network provider at this time. 
 
You asked the Plan to pre-approve the dental services. You say that you would like the Plan to reconsider their 
denial as there are no in-network Endodontist's available to provide the necessary services in your area. The 
Plan denied your request. The Plan says dental services from an out-of-network provider are not covered by 
your supplemental benefits. However, the Plan has stated that there are no in-network providers located in 
proximity to you. Therefore, the Plan has contacted the requested out-of-network provider and has agreed to a 
single case agreement to see you for a consultation, x-rays, pulp vitality testing, and cone beam computed 
tomography (CT) imaging in order to determine treatment needs. The Plan says if further treatment is required, 
the office will work with care coordination with the out-of-network provider to negotiate payment for those 
services. 
 
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 are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under this benefit when received 
from an out-of-network provider. However, the Plan has stated that there are no in-network providers located in 
proximity to you. Therefore, the Plan has contacted the requested out-of-network provider and has agreed to a 
single case agreement to see you for a consultation, x-rays, pulp vitality testing, and cone beam computed 
tomography (CT) imaging in order to determine treatment needs. The Plan says if further treatment is required, 
the office will work with care coordination with the out-of-network provider to negotiate payment for those 
services. Therefore, we decided that the Plan does not have to pre-approve endodontic therapy (D3320) to be 
provided by an out-of-network provider at this time.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient rehabilitation services (97530) 
provided on August 4, 2022 to August 25, 2022. 
 
You asked the Plan to waive the copayment for the outpatient rehabilitation services. You say that the services 
should be covered as you disagree with the denial and the charges would cause a financial hardship. The Plan 
denied your request. The Plan says this cost sharing was charged correctly. 
 
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 $35 
copayment per visit for Outpatient rehabilitation services.  
 
 
  You have been asked to pay a $210 copayment per visit for six outpatient rehabilitation visits. This 
item/service falls within the Outpatient rehabilitation 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 outpatient rehabilitation services (97530) provided on August 4, 2022 to August 
25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services (D7210, D9223, D9222, D9612) provided on 
January 18, 2022. 
 
You asked the Plan to pay for the dental services. 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 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 dental 
services (D7210, D9223, D9222, D9612) provided on January 18, 2022.