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

 
We decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on August 15, 2022. 
 
You asked the Plan to pay for the panoramic x-ray. You say that this x-ray was needed as part of the provider's 
evaluation of your bone growth in preparation for the implant. 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 13, 2022. 
Therefore, we decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on August 
15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and intraoral 
imaging (D0210) provided by a participating provider on February 18, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are in a lot of pain and needed these 
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 January 25, 2022. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and 
intraoral imaging (D0210) provided by a participating provider on February 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an additional intraoral image (D0230) provided by an out-of-
network provider on July 13, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were never told that this provider was out-
of-network. 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 13, 2022. Therefore, 
we decided that the Plan does not have to pay for an additional intraoral image (D0230) provided by an out-of-
network provider on July 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an extraction (D7140) provided by an oral surgeon. 
 
You asked the Plan to pre-approve an extraction. You say that this service is medically necessary. The Plan 
denied your request. The Plan says an extraction is not covered when received by an oral surgeon. 
 
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 item or service is not 
among those covered under this benefit when received by an oral surgeon. Therefore, we decided that the Plan 
does not have to pre-approve an extraction (D7140) provided by an oral surgeon.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture treatments (97810, 97811) provided on  
June 15, 2022 and June 29, 2022. 
 You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the enrollee has exhausted the allowable 
benefit for these services. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services provided have not been met. Specifically, the Medicare rules say that no more than 20 
acupuncture sessions per year are covered. The enrollee previously received 25 acupuncture treatments from 
April 13, 2022, through July 13, 2022 that were paid for by the Plan. Therefore, the enrollee has exhausted the 
allowable benefit for these services. Therefore, we decided that the Plan does not have to pay for the 
acupuncture treatments (97810, 97811) provided on June 15, 2022 and June 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the upper partial denture (D5213) and complete lower 
denture (D5120). 
 
You asked the Plan to pre-approve the dental services. You say that you are not able to eat properly without 
these dentures. The Plan denied your request. The Plan says your benefit for the complete lower denture 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 December 5, 2019. This 
benefit does not include partial dentures. Therefore, we decided that the Plan does not have to pre-approve the 
upper partial denture (D5213) and complete lower denture (D5120).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the EMG provided on May 9, 2022. 
 
You asked the Plan to waive the copayment for the EMG. You say that the services rendered did not work. 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 $150 
copayment for diagnostic procedures.  
 
You have been asked to pay $81.81 for the EMG, which is less than the standard $150 copayment. This 
item/service falls within the diagnostic procedures 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 EMG provided on May 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on June 28, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should have been covered. The Plan 
denied your request. The Plan says the services are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental 
services on June 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation and intraoral complete 
series x-rays provided on June 23, 2022. 
 
You asked the Plan to pay for the dental services. You say that you needed to see a new provider and you were 
not informed about the benefit limitations for these services. 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 June 25, 2020. 
Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation and intraoral 
complete series x-rays provided on June 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740) provided by an out-of-network provider on 
May 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that the Plan switched around your primary and 
secondary benefits. You say that you should still have money left. 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 7, 2022. Therefore, 
we decided that the Plan does not have to pay for a crown (D2740) provided by an out-of-network provider on 
May 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on May 16, 2022. 
 
You asked the Plan to pay for dental services. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says these services have been correctly denied. 
 
The Plan must follow Medicare rules. Medicare rules say that if a provider has been excluded/sanctioned, they 
are not eligible for participation; therefore, any services provided are not payable.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of dental services have not been met. Therefore, we decided that the Plan does not have to pay for 
dental services provided on May 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided on June 
29, 2022. 
 
You asked the Plan to pay for a panoramic radiographic image. You say that you were not aware that the 
service would not be covered. 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 a 
panoramic radiographic image (D0330) provided on June 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal of impacted tooth (D7220) provided on June 20, 
2022. 
 
You asked the Plan to pay for the dental services. You say that the claim used the wrong procedure code. The 
Plan denied your request. The Plan says this service is not a covered benefit 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, 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 
removal of impacted tooth (D7220) provided on June 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on November 18, 2021. 
 
You asked the Plan to pay for the dental services. You say that the services requested are medically necessary. 
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 dental services on November 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oral evaluation (D0140) provided on June 24, 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 May 23, 2022. Therefore, 
we decided that the Plan does not have to pay for an oral evaluation (D0140) provided on June 24, 2022
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120) and prophylaxis (D1110) 
provided on April 13, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were not told you needed to stay in-
network. 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 periodic oral evaluation (D0120) and prophylaxis (D1110) provided on April 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the periodic oral evaluation, prophylaxis, first intraoral 
periapical x-ray, and resin-based composites provided on January 25, 2022, and April 26, 2022, by an out-of-
network (OON) provider. 
 
  You asked the Plan to pay more for the dental services. You say that you thought this service would be covered 
because the treating provider says they are in-network. The Plan denied your request. The Plan says these 
services have processed as OON correctly, and the cost share has been applied based on the 2022 Evidence of 
Coverage. 
 
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 a 50% coinsurance for the covered dental services because they were rendered by 
an OON provider. 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 periodic oral evaluation, 
prophylaxis, first intraoral periapical x-ray, and resin-based composites provided on January 25, 2022, and 
April 26, 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 the cone beam computed tomography (CT) capture and 
interpretation (D0364) provided on May 23, 2022. 
 
You asked the Plan to pay for the cone beam CT capture and interpretation. You say that this x-ray was 
necessary, and you believe it should be covered. The Plan denied your request. The Plan says this service is not 
a covered benefit 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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the cone 
beam computed tomography (CT) capture and interpretation (D0364) provided on May 23, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a panoramic radiographic image (D0330), and extraction, erupted 
tooth or exposed root (elevation and/or forceps removal) tooth #1 (D7140). 
 
You asked the Plan to pre-approve the dental services. 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. Therefore, we decided that the Plan has to pre-approve a panoramic radiographic image (D0330), 
and extraction, erupted tooth or exposed root (elevation and/or forceps removal) tooth #1 (D7140).  
 
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 endodontic therapy (D3330) provided on July 18, 2022. 
 
You asked the Plan to pay for endodontic therapy. You say that you thought this service was covered. 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 
endodontic therapy (D3330) provided on July 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system, Tru-Balance armrest 
bracket, expandable controller upgrade with harness, and electronic connection. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that an expandable controller is used to control 
multiple power options. The rules say that a power seat elevation system is not covered because it is not 
primarily medical in nature. The rules say that armrests are described by procedure codes K0015, K0017, 
K0018, and K0020. 
 
We looked at the file and Medicare rules. The file shows that the expandable harness is not needed to control 
the approved power switches. The power seat elevation system is not covered by Medicare. The armrests are 
not being requested under the correct procedure code. Based on this information, we decided that Medicare 
rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a power seat elevation system, Tru-Balance armrest bracket, expandable controller upgrade with 
harness, and electronic connection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a surgical extraction (D7210) provided by an out-of-network 
provider on July 1, 2022. 
 
You asked the Plan to pay for a surgical extraction. You say that you needed these services. The Plan denied 
your request. The Plan says these services have been correctly denied. 
 
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 surgical 
extraction (D7210) provided by an out-of-network provider on July 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a consultation (D9310) and cone beam imaging (D0364) 
provided on July 7, 2022. 
 
You asked the Plan to pay for a consultation and imaging. You say that you disagree with the denial of dental 
services. The Plan denied your request. The Plan says a consultation (D9310) and cone beam imaging (D0364) 
are not covered by your routine dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 
consultation (D9310) and cone beam imaging (D0364) provided on July 7, 2022.