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

 
We decided that the Plan does not have to pay for the interpretation of diagnostic image (D0391) and collection 
and application of autologous blood concentrate product (D7921), or pay more for the problem focused limited 
oral evaluation (D0140), and surgical extraction (D7210) provided on April 8, 2022, by an out-of-network 
(OON) provider. 
 You asked the Plan to pay for the interpretation of diagnostic image and collection and application of 
autologous blood concentrate product, and to pay more for the problem focused limited oral evaluation, and 
surgical extraction. You say that there are no oral surgeons within 100 miles of your residence, and you could 
not have gone to an in-network provider. You also say that you believe you should be reimbursed for what 
would have been paid to an in-network dentist. The Plan denied your request. The Plan says the interpretation 
of diagnostic image and collection and application of autologous blood concentrate product are not covered 
expenses under your dental plan. The Plan also says that these services were performed by a non-participating 
provider, and you are responsible for any difference between the Maximum Allowable Fee and the amount the 
provider bills you for the 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the interpretation of diagnostic image 
(D0391) and collection and application of autologous blood concentrate product (D7921) are not among those 
covered under this benefit. The contract also says that you are responsible for a 50% coinsurance for the 
problem focused limited oral evaluation (D0140), a 55% coinsurance for the surgical extraction (D7210), plus 
the difference between the billed amounts and allowed amounts because these services were received OON. 
Therefore, we decided that the Plan does not have to pay for the interpretation of diagnostic image (D0391) and 
collection and application of autologous blood concentrate product (D7921), or pay more for the problem 
focused limited oral evaluation (D0140), and surgical extraction (D7210) provided on April 8, 2022, by an out-
of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a crown on tooth #19 (D2751) provided on May 25, 
2022. 
 
You asked the Plan to pay more for a crown. You say that this procedure was an emergency. The Plan denied 
your request. The Plan says your dental allowance has been exhausted. 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 have a $1,000 
allowance for preventive and comprehensive dental services. The contract says that you are responsible for any 
amount above the coverage limit. 
 
The record shows your dental allowance has been exhausted. You have been asked to pay $155 for a crown. 
This item/service falls within the dental 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 pay more for 
a crown on tooth #19 (D2751) provided on May 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prefabricated abutment (D6056), a maxillary 
implant/abutment supported fixed denture (D6114), a mandibular implant/abutment supported fixed denture 
(D6115), and an endosteal implant (D6010), provided by a participating provider. 
 
You asked the Plan to pre-approve a prefabricated abutment, a maxillary implant/abutment supported fixed 
denture, a mandibular implant/abutment supported fixed denture, and an endosteal implant. You say that you 
need this dental work. The Plan denied your request. The Plan says the requested dental 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 pre-approve a 
prefabricated abutment (D6056), a maxillary implant/abutment supported fixed denture (D6114), a mandibular 
implant/abutment supported fixed denture (D6115), and an endosteal implant (D6010), provided by a 
participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a problem focused limited oral evaluation on May 23, 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 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 a problem focused limited oral evaluation on May 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of residual tooth roots on teeth # 2, 4, 5, 7, 8, 9, 
10, 12, 13, 14, 15, 21, 27 (D7250), bone replacement grafts on teeth #27, 2, 4, 5, 7, 8, 9, 10, 12, 13, 14, 15, 21 
(D7983), therapeutic parenteral drug (D9610) and upper & lower dentures (5130, 5110, 5226). 
 
You asked the Plan to pre-approve dental services. You say that the enrollee needs the requested dental 
services, and you feel the services should be covered. 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. Removal of residual tooth 
roots (D7250), bone replacement grafts (D7983), therapeutic parenteral drug (D9610) and upper & lower 
dentures (5130, 5110, 5226) are not covered under the Plans dental benefits. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested removal of residual tooth 
roots on teeth # 2, 4, 5, 7, 8, 9, 10, 12, 13, 14, 15, 21, 27 (D7250), bone replacement grafts on teeth #27, 2, 4, 5, 
7, 8, 9, 10, 12, 13, 14, 15, 21 (D7983), therapeutic parenteral drug (D9610) and upper & lower dentures (5130, 
5110, 5226) are not among those covered under this benefit. Therefore, we decided that the Plan does not have 
to pre-approve removal of residual tooth roots on teeth # 2, 4, 5, 7, 8, 9, 10, 12, 13, 14, 15, 21, 27 (D7250), 
bone replacement grafts on teeth #27, 2, 4, 5, 7, 8, 9, 10, 12, 13, 14, 15, 21 (D7983), therapeutic parenteral drug 
(D9610) and upper & lower dentures (5130, 5110, 5226).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lightweight wheelchair (K0003). 
 
You asked the Plan to pre-approve a lightweight wheelchair. You say that you do not have a designated 
caregiver. Therefore, a lightweight wheelchair is a necessity for you to remain independent and complete your 
activities of daily living. The Plan denied your request. The Plan says you do not meet criteria for coverage of 
the requested wheelchair. Notes do not state you can or cannot propel wheelchair, but it states there is a 
caregiver who will propel the wheelchair. Nothing justifies the use of an ultralight wheelchair in this care. Care 
could be met with a standard wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a lightweight wheelchair. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found the documentation is conflicting 
that you have a mobility deficit that impairs MRADLs in the home. The face-to-face states there is a mobility 
deficit and that you have balance issues and an ineffective left upper extremity grip and profound left upper 
extremity motor deficits. The physical examination is not consistent with this finding. You are noted on exam 
able to ambulate without an issue on your own accord. The neurologic exam is also noted to be without focal 
deficits. Additionally, there is no evidence that you cannot use a standard wheelchair over a lightweight 
wheelchair. The requested wheelchair exceeds your medical needs, as Medicare does not pay for any items or 
services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve 
the functioning of a malformed body member. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a lightweight wheelchair have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a lightweight wheelchair (K0003).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implant placement for tooth 30 (D6010), prefabricated 
abutment for tooth 30 (D6056) and implant supported porcelain/ceramic crown for tooth 30 (D6065). 
 
You asked the Plan to pre-approve dental services. You say that your previous dental services were approved, 
now you don't understand why these services are not being covered. 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), 
prefabricated abutment (D6056) and implant supported porcelain/ceramic crown (D6065) are not covered 
under the Plans dental benefits. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested implant placement for 
tooth 30 (D6010), prefabricated abutment for tooth 30 (D6056) and implant supported porcelain/ceramic crown 
for tooth 30 (D6065) are not among those covered under this benefit. Therefore, we decided that the Plan does 
not have to pre-approve implant placement for tooth 30 (D6010), prefabricated abutment for tooth 30 (D6056) 
and implant supported porcelain/ceramic crown for tooth 30 (D6065).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prefabricated abutment a crown restoration (D6065, 
D6056) 
 
You asked the Plan to pre-approve prefabricated abutment crown restoration. 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 a 
prefabricated abutment a crown restoration (D6065, D6056)
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for immediate denture - maxillary (D5130x2), drugs or 
medicaments dispensed in the office for home use (D9630x2), alveoloplasty in conjunction with extractions - 
four or more teeth or tooth spaces, per quadrant (D7310x2), and bone replacement graft for ridge preservation - 
per site (D7953x2). 
 
You asked the Plan to pay for dental services. You say that you are requesting a standard appeal for the 
services already received. The Plan denied your request. The Plan says immediate denture - maxillary 
(D5130x2), drugs or medicaments dispensed in the office for home use (D9630x2), alveoloplasty in 
conjunction with extractions - four or more teeth or tooth spaces, per quadrant (D7310x2), and the bone 
replacement graft for ridge preservation - per site (D7953x2) are not covered under the benefit package. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
immediate denture - maxillary (D5130x2), drugs or medicaments dispensed in the office for home use 
(D9630x2), alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, per quadrant 
(D7310x2), bone replacement graft for ridge preservation - per site (D7953x2). The Plan agreed to pay for the 
extraction, erupted tooth or exposed root (D7140), and extraction, erupted tooth requiring removal of bone 
and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) provided on 
March 8, 2022 to March 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on July 12, 2022. 
 
You asked the Plan to pay for periodontal maintenance (D4910). You say that you get two cleanings twice a 
year and it is constantly denied because it's a deep cleaning. The Plan denied your request. The Plan says this 
service is not covered under the benefit package. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
periodontal maintenance (D4910) provided on July 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on June 23, 2022. 
 
You asked the Plan to pay for an evaluation. You say that you disagree with the denial of 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 January 24, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on 
June 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation - problem focused (D0140), and 
panoramic radiographic image (D0330) provided on June 8, 2022. 
 
You asked the Plan to pay for the limited oral evaluation - problem focused (D0140), and panoramic 
radiographic image (D0330). You say that you were directed to see a dentist due to painful TMJ symptoms. 
You say it was determined that there was nothing abnormal found and advised to try a biting guard. The Plan 
denied your request. The Plan says these services are not covered under the benefit package. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a limited 
oral evaluation - problem focused (D0140), and panoramic radiographic image (D0330) provided on June 8, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an apicoectomy - anterior tooth #9 (D3410), and guided 
tissue regeneration, resorbable barrier, per site, in conjunction with periradicular surgery tooth #9 (D3432) 
provided on May 16, 2022. 
 
 
You asked the Plan to pay for an apicoectomy - anterior tooth #9 (D3410), and guided tissue regeneration, 
resorbable barrier, per site, in conjunction with periradicular surgery tooth #9 (D3432). You say that a 
predetermination of benefits was obtained, then subsequently denied coverage upon claim submission. The 
Plan denied your request. The Plan says these services are not covered under the benefit package. 
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an 
apicoectomy - anterior tooth #9 (D3410), and guided tissue regeneration, resorbable barrier, per site, in 
conjunction with periradicular surgery tooth #9 (D3432) provided on May 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for occlusal guard  hard appliance, full arch (D9944) provided 
on February 17, 2022. 
 
You asked the Plan to pay for dental services. You say that you are missing teeth; therefore, you hope the Plan 
will pay for the service. 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. Occlusal guard  hard 
appliance, full arch is not covered under the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested occlusal guard  hard 
appliance, full arch (D9944) is not among those covered under this benefit. Therefore, we decided that the Plan 
does not have to pay for occlusal guard  hard appliance, full arch (D9944) provided on February 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral evaluation  problem (D0140) provided on July 
6, 2022. 
 
You asked the Plan to pay for dental services. You say that your oral evaluation should be covered. 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. Limited oral evaluation  
problem (D0140) is not covered under the Plans dental benefits 
 
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 limited 
oral evaluation  problem (D0140) provided on July 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive periodontal evaluation (D0180) provided 
on June 1, 2022. 
 
You asked the Plan to pay for a comprehensive periodontal evaluation (D0180). You say that the exam was 
necessary to determine that you have periodontal disease and need a deep cleaning. The Plan denied your 
request. The Plan says a comprehensive periodontal evaluation (D0180) is not a covered dental service under 
your plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
comprehensive periodontal evaluation (D0180) provided on June 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral evaluation (D0120), the cleaning (D1110), and the x-
rays (D0274) provided by June 21, 2022. 
 
You asked the Plan to pay for the dental services. You say that you did not know that the dental office was out-
of-network. You say the dental office did not tell you that they do not accept your insurance. 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), the cleaning (D1110), and the x-rays (D0274) provided by June 21, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite (D2332) provided by an out-of-
network provider on June 23, 2022. 
 
You asked the Plan to pay for the dental services. You say that this dental visit was an emergency. The Plan 
denied your request. The Plan says your annual maximum dental benefit amount has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your annual maximum dental benefit amount was exhausted on date of service May 25, 2022. Therefore, 
we decided that the Plan does not have to pay for a resin-based composite (D2332) provided by an out-of-
network provider June 23, 2022.