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

 
We decided that the Plan does not have to pay for an immediate denture - maxillary (D5130), and immediate 
denture - mandibular (D5140) provided on June 10, 2022, extraction, erupted tooth or exposed root (elevation 
and/or forceps removal) (D7140), bone replacement graft for ridge preservation - per site (D7953), deep 
sedation/general anesthesia  first 15 minutes (D9222), and deep sedation/general anesthesia  each subsequent 
15 minute increment (D9223) provided on July 11, 2022. 
 
You asked the Plan to pay for the dental services. You say that your dental plan is inadequate for the 
procedures you 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 extraction, erupted tooth or exposed root (elevation and/or forceps removal) 
(D7140) was exhausted on date of service July 11, 2022. The Plan covered two extractions and you received 
another 10 units of the extraction at the same visit. 
 
The Plan has corrected the claim for the deep sedation/general anesthesia  first 15 minutes (D9222), deep 
sedation/general anesthesia  each subsequent 15 minute increment (D9223) and has been reprocessed 
according to the Plan benefits. 
 
Therefore, we decided that the Plan does not have to pay for an immediate denture - maxillary (D5130), and 
immediate denture - mandibular (D5140) provided on June 10, 2022, extraction, erupted tooth or exposed root 
(elevation and/or forceps removal) (D7140), bone replacement graft for ridge preservation - per site (D7953),  
deep sedation/general anesthesia  first 15 minutes (D9222), and deep sedation/general anesthesia  each 
subsequent 15 minute increment (D9223), and provided on July 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a diagnostic consultation (D9310), a cone beam computed 
tomography (CT) capture (D0364), an intraoral x-ray (D0220. D0230), endodontic therapy, molar tooth 
(D3330), and core buildup (D2950) provided on May 6, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were on vacation and cracked your rear 
molar. 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 a diagnostic consultation (D9310), a cone beam computed tomography (CT) capture (D0364), an 
intraoral x-ray (D0220. D0230), endodontic therapy, molar tooth (D3330), and core buildup (D2950) provided 
on May 6, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a tooth extraction for tooth #14 (D7210) 
 
You asked the Plan to pre-approve 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 that the dental services are denied 
because an extraction for tooth #14 was already performed in 2020. 
 
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. Therefore, we decided that the Plan has to pre-approve a tooth extraction for tooth #14 (D7210)  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation, resin-based 
composites three surfaces for tooth #s 25, 26, 27 and a resin-based composite two surfaces for tooth #28 
provided on June 23, 2022. 
 
You asked the Plan to pay for the dental services. You say that you cannot afford to pay this claim. The Plan 
denied your request. The Plan says your benefit for the requested items or services has already been exhausted 
or was a service 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 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 June 23, 2022, when the 
Plan paid for the restoration of tooth #s 23 and 24. Additionally, the problem focused limited oral evaluation is 
not among the services covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
the problem focused limited oral evaluation, resin-based composites three surfaces for tooth #s 25, 26, 27 and 
a resin-based composite two surfaces for tooth #28 provided on June 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction, erupted tooth requiring removal of bone and/or 
sectioning of tooth and including elevation of mucoperiosteal flap if indicated tooth #'s 25, 26, 27 and 28 
(D7210) provided on June 24, 2021. 
 
You asked the Plan to pay for the dental services. 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 June 24, 2021. Therefore, 
we decided that the Plan does not have to pay for an extraction, erupted tooth requiring removal of bone and/or 
sectioning of tooth and including elevation of mucoperiosteal flap if indicated tooth #'s 25, 26, 27 and 28 
(D7210) provided on June 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on February 15, 2022. 
 
You asked the Plan to pay for the dental services. You say that you did not know you had an assigned 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 dental services provided on February 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for manual therapy techniques (97140) and office visit (99203) 
provided on May 30, 2022, to June 10, 2022. 
 You asked the Plan to pay for chiropractic services. You say that you feel the services should be covered. The 
Plan denied your request. The Plan says these are non-covered services. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. 
 
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 In-
network Medicare-covered chiropractic services $20 copayment  specialists office.  
 
You have been asked to pay $80 for chiropractic manipulative treatment (98940) ($20 x 4 = $80). Chiropractic 
manipulative treatment falls within the Chiropractic services benefits 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. The records show that the manual therapy 
techniques (97140) xs 4 and office visit (99203) is not manual manipulation of the spine. Therefore, we 
decided that the Plan does not have to pay for manual therapy techniques (97140) xs 4 and office visit (99203) 
provided on May 30, 2022, to June 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and a complete 
intraoral x-ray series (D0210) provided on June 30, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were unaware that you received the same 
services two years ago. The Plan denied your request. The Plan says your benefit for the requested items or 
services 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 items or services was exhausted on date of service December 1, 2020. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and a 
complete intraoral x-ray series (D0210) provided on June 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services () provided on April 7, 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 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 April 7, 2022. Therefore, 
we decided that the Plan does not have to pay for dental services () provided on April 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gingival irrigation (D4921) and periodontal scaling and root 
planing (D4341) provided by an out-of-network provider on June 4, 2022, to June 6,2022. 
 
You asked the Plan to pay for the dental services. You say that you thought that this would be covered. 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, D4341 is not covered under this benefit when received 
from an out-of-network provider. D4921 is not a covered benefit. Therefore, we decided that the Plan does not 
have to pay for gingival irrigation (D4921) and periodontal scaling and root planing (D4341) provided by an 
out-of-network provider on June 4, 2022, to June 6,2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gingival irrigation - per quadrant (D4921), drugs or 
medicaments dispensed in the office for home use (D9630) and adjunctive pre-diagnostic test that aids in 
detection of mucosal abnormalities including premalignant and malignant lesions, not to include cytology or 
biopsy procedures (D0431) provided on August 15, 2022, to August 18, 2022. 
 You asked the Plan to pay for dental services. You say that you say that you did not know the provider was out-
of-network. The Plan denied your request. The Plan says these services are not covered benefits even if 
provided 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 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. These services are not covered even if they were provided by an in-
network provider. Therefore, we decided that the Plan does not have to pay for gingival irrigation - per 
quadrant (D4921), drugs or medicaments dispensed in the office for home use (D9630) and adjunctive pre-
diagnostic test that aids in detection of mucosal abnormalities including premalignant and malignant lesions, 
not to include cytology or biopsy procedures (D0431) provided on August 15, 2022, to August 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oral/facial photographic image (D0350) provided on 
August 10, 2022 
 
You asked the Plan to pay for an oral/facial photographic image. You say that you want the Plan to pay for the 
service. The Plan denied your request. The Plan says the service at issue is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an 
oral/facial photographic image (D0350) provided on August 10, 2022
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a prophylaxis - adult (D1110) provided on December 1, 
2021. 
 
You asked the Plan to pay for the prophylaxis - adult (D1110). 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 July 22, 2021. Therefore, 
we decided that the Plan does not have to pay for a prophylaxis - adult (D1110) provided on December 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone graft at time of implant placement (D6104). 
 
You asked the Plan to pre-approve bone graft at time of implant placement (D6104). You say that you are 
appealing with supporting records. The Plan denied your request. The Plan says this service and code is not 
listed and is a non-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 pre-approve bone 
graft at time of implant placement (D6104).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the crown (D2740) provided on July 22, 2022. 
 
You asked the Plan to pay for the dental service. You say that the dental office should have determined if the 
procedure was covered before providing the service. 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. Specifically, the Plan did not submit a claim or Explanation of Benefits showing the Plan previously 
paid for a crown. Therefore, we decided that the Plan has to pay for the crown (D2740) provided on July 22, 
2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71045 billed for date of service July 15, 
2022. 
 
You asked the Plan to pay for procedure code 71045. You say that the enrollee had multiple exams on this date 
of service and the attached reports support this level of service. You say that the claim should be reconsidered 
for processing. The Plan denied your request. The Plan says payment for code 71045 is bundled into payment 
for code 32555.  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 71045 
is a column II code to column I code 32555. 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 71045 billed for date of service July 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an adjunctive pre-diagnostic test (D0431) provided on 
August 2, 2022. 
 
You asked the Plan to pay for an adjunctive pre-diagnostic test. You say that you were not aware that the 
provider was out-of-network. The Plan denied your request. The Plan says the service at issue is not a covered 
benefit. 
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an 
adjunctive pre-diagnostic test (D0431) provided on August 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve biologic materials (D3431) 
 
You asked the Plan to pre-approve 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 pre-approve 
biologic materials (D3431)
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray services coded 73562 and 73630 provided on July 
27, 2022. 
 
You asked the Plan to pay for the x-ray services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services are not payable as billed. 
 
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 73562 and 73630 is not supported in the medical record. Specifically, these codes have 
a status indicator of Q1. Code 99284 was billed on the same date of service with a revenue code of 450 which 
has a status indicator of "V". This means codes the 73562 and 73630 are not separately payable as billed. Based 
on this information, we decided that Medicare rules for coverage of the x-ray services have not been met. 
Therefore, we decided that the Plan does not have to pay for the x-ray services coded 73562 and 73630 
provided on July 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the tooth extraction (D7140) 
 
You asked the Plan to pre-approve 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 dental services from an out-of-network 
provider 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. 
 
 
  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. Therefore, we decided that the Plan does not have to pre-approve the tooth 
extraction (D7140)