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

 
We decided that the Plan does not have to pre-approve the upper partial denture (D5213) and the lower partial 
denture (D5214). 
 
You asked the Plan to pre-approve the dental services. You say that you need replacement dentures because the 
old ones were lost in a house fire. 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 January 22, 2021. 
Therefore, we decided that the Plan does not have to pre-approve the upper partial denture (D5213) and the 
lower partial denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation and the surgical extraction 
provided on June 21, 2022. 
 
You asked the Plan to pay for the dental service. You say that this was surgery, and it should 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, 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 limited oral evaluation and the surgical extraction provided on June 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the immediate denture - mandibular (D5140) provided on 
May 11, 2022. 
 
You asked the Plan to pay for the immediate lower denture. You say that you feel the wrong code was used. 
The Plan denied your request. The Plan says this service is not covered under your benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
immediate denture - mandibular (D5140) provided on May 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental surgery and anesthesia. 
 
You asked the Plan to pre-approve the dental surgery and anesthesia. You say that general anesthesia is for the 
safety of this patient. 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 pre-approve the 
dental surgery and anesthesia.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal of an impacted tooth (D7240) provided May 12, 
2022. 
 
You asked the Plan to pay for the removal of an impacted tooth. 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 the 
removal of an impacted tooth (D7240) provided May 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral radiographic images (D0230) and the risk 
assessment and documentation (D0602) provided on April 26, 2022. 
 
You asked the Plan to pay for the dental services. You say that the Plan covers x-rays, and these dental services 
should be covered. The Plan denied your request. The Plan says your benefit for the requested item or service 
has already been exhausted. Also, the risk assessment and documentation 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, certain limitations apply. The record 
shows your benefit for the intraoral radiographic images was exhausted on the date of service of April 26, 
2022. The risk assessment and documentation are not covered under the Plans dental benefits. Therefore, we 
decided that the Plan does not have to pay for intraoral radiographic images (D0230) and the risk assessment 
and documentation (D0602) provided on April 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the interim complete denture (maxillary) (D5810). 
 
You asked the Plan to pre-approve the interim complete upper denture. You say that you need this service 
covered. The Plan denied your request. The Plan says this service is not covered under your benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
interim complete denture (maxillary) (D5810).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the complete upper denture (D5110) and the complete 
lower denture (D5120). 
 
You asked the Plan to pre-approve the dental services. You say that it is necessary for the enrollee to receive 
dentures because they are unable to eat. The Plan denied your request. The Plan says the denial of authorization 
for these services is correct, because complete dentures 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 pre-approve the 
complete upper denture (D5110) and the complete lower denture (D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the complete denture - mandibular (D5120) provided 
on July 25, 2022. 
 
You asked the Plan to pay more for the complete lower denture. You say that you were told your services 
would be covered. The Plan denied your request. The Plan says you have exhausted your dental 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. The Plan covers the complete 
lower denture up to a $2,000 annual maximum.  
 
We looked at the file and Medicare rules. The Plan provided documentation showing that your full dental 
allowance was applied to your dentures provided on July 25, 2022. You are responsible for the remaining amount above the dental allowance. Therefore, we decided that the Plan does not have to pay more for the 
complete denture - mandibular (D5120) provided on July 25, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve the dental services. 
 
You asked the Plan to pre-approve the dental services. You say that the services requested are medically 
necessary. The Plan denied your request. The Plan says that the authorization has been approved. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the dental 
services when the services are medically necessary and reasonable. 
 
Based on this information, we decided that the Plan's rules for coverage of the dental services have been met. 
Therefore, we decided that the Plan has to pre-approve the dental services.  
 
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 more for the limited oral evaluation (D0140), the intraoral x-ray 
(D0220), the apicoectomy (D3421), and the retrograde filling (D3430) provided on July 27, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you were told you would be responsible 
for 70% to 80% of the cost. You say you had to have the procedure done. 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. The 
apicoectomy (D3421), and the retrograde filling (D3430) are not among those covered under this benefit.  Therefore, we decided that the Plan does not have to pay more for the limited oral evaluation (D0140), the 
intraoral x-ray (D0220), the apicoectomy (D3421), and the retrograde filling (D3430) provided on July 27, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive periodontal evaluation - new or 
established patient (D0180) provided on July 6, 2022. 
 
You asked the Plan to pay for the comprehensive periodontal exam. You say that you would like this service 
covered. The Plan denied your request. The Plan says this service is not covered under your benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
comprehensive periodontal evaluation - new or established patient (D0180) provided on July 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a lower partial denture (D5214) provided on May 23, 
2022. 
 
You asked the Plan to pay more for the dental services. You say that you feel this claim should be 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 date of service May 23, 2022.  
 
 
 
 The Plan made a partial payment on this claim in the amount of $607.50 before reaching the maximum annual 
allowance for dental services. You are responsible for paying the remaining $435 on this claim. Therefore, we 
decided that the Plan does not have to pay more for a lower partial denture (D5214) provided on May 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance services (D4910) provided on July 
19, 2022. 
 
You asked the Plan to pay for the periodontal maintenance 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 
periodontal maintenance services (D4910) provided on July 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on April 12, 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 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 April 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the occlusal guard (D9944). 
 
You asked the Plan to pre-approve the dental service. You say that it is necessary for you to get the guard so it 
will help when you grind your teeth. The Plan denied your request. The Plan says the denial of authorization 
for this service is correct, because the occlusal guard 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 the 
occlusal guard (D9944).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implant placement (D6010) for teeth 4, 6, 11 and 13. 
 
You asked the Plan to pre-approve dental services. You say that you really need the implants. 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. Implant placement (D6010) is 
not covered under the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested implant placement 
(D6010) for teeth 4, 6, 11 and 13 is not among those covered under this benefit. Therefore, we decided that the 
Plan does not have to pre-approve implant placement (D6010) for teeth 4, 6, 11 and 13.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pontic (D6240) and the retainer crown (D6750) provided 
on May 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that you had dental coverage during the date of 
service and the services should be covered. The Plan denied your request. The Plan says the denial of payment 
for these services is correct, because pontics and the retainer crown 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 pontic 
(D6240) and the retainer crown (D6750) provided on May 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an unspecified preventive procedure (D1999) and periapical 
x-rays (D0220, D0230) provided on March 8, 2022. 
 
You asked the Plan to pay for a preventive procedure and x-rays. You say that you were supposed to see a 
provider that was in-network. The Plan denied your request. The Plan says an unspecified preventive procedure 
(D1999) and periapical x-rays (D0220, D0230) are not covered by 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 an 
unspecified preventive procedure (D1999) and periapical x-rays (D0220, D0230) provided on March 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve fixed partial denture sectioning (D9120), surgical 
placement of implant body: endosteal implant (D6010), and custom fabricated abutment  includes placement 
(D6057). 
 
You asked the Plan to pre-approve fixed partial denture sectioning, endosteal implant and custom fabricated 
abutment. You say that you are experiencing pain when eating which is affecting your health. The Plan denied 
your request. The Plan says these services are not covered under your benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve fixed partial denture sectioning (D9120), surgical placement of implant body: endosteal implant (D6010), and 
custom fabricated abutment  includes placement (D6057).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the endodontic therapy (D3320 and D3330) for tooth 
#5, #16, and #29. 
 
You asked the Plan to pre-approve the dental services. You say that the Plan should cover these procedure 
codes because you have not hit your benefit limit. The Plan denied your request. The Plan says the denial of 
authorization for these services is correct, because endodontic therapy 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 the 
endodontic therapy (D3320 and D3330) for tooth #5, #16, and #29.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the oral evaluation (D0140), the intraoral radiographic 
image (D0220 and D0230), and an extraction (D7140) for tooth #19 and #29 provided on May 11, 2022. 
 
You asked the Plan to pay more for the dental services. You say that the provider never told you that they were 
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 the oral evaluation (D0140), the intraoral 
radiographic image (D0220 and D0230), and an extraction (D7140) for tooth #19 and #29 provided on May 11, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for onlay dental service (D2643) provided on June 7, 2022. 
 
You asked the Plan to pay for the onlay dental service. 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 onlay 
dental service (D2643) provided on June 7, 2022.