Persius/hicric huggingface dataset:
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 with field of view of one full dental arch - maxilla, with or without cranium (D0366), limited 
oral evaluation - problem focused (D0140), and endodontic therapy, molar tooth (excluding final restoration) 
(D3330) provided August 7, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the cone beam CT scan, limited oral exam and root canal. You say that this was 
an emergency situation and should be covered. The Plan denied your request. The Plan says these services are 
not covered because they were provided OON. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the cone 
beam CT scan, limited oral exam and root canal when rendered by a provider in the Plan's network.  
We looked at file and Medicare rules. In this case the services were provided by an OON provider. Based on 
this information, we decided that the Plan's rules for coverage of the cone beam CT scan, limited oral exam and 
root canal have not been met. Therefore, we decided that the Plan does not have to pay for the cone beam 
computed tomography (CT) capture and interpretation with field of view of one full dental arch - maxilla, with 
or without cranium (D0366), limited oral evaluation - problem focused (D0140), and endodontic therapy, molar 
tooth (excluding final restoration) (D3330) provided August 7, 2021, 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 comprehensive oral evaluation (D0150), prophylaxis 
(D1110), complete series x-ray (D0210) and filling (D2330) provided from September 13, 2021, to October 5, 2021. 
 
You asked the Plan to pay for the dental services. You say that you were not advised you could only see certain 
providers, only that the office was in network. You also say that this provider is in network as of October 29, 
2021. The Plan denied your request. The Plan says the provider in this case was out of network on the dates of 
service in this case. The Plan also says that dental services received out of network are not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, dental services received out of network 
are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
the comprehensive oral evaluation (D0150), prophylaxis (D1110), complete series x-ray (D0210) and filling 
(D2330) provided from September 13, 2021, to October 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete denture - maxillary (D5110) and complete 
denture - mandibular (D5120) provided December 2, 2021. 
 
You asked the Plan to pay for the complete upper and lower denture. You say that you were advised by the 
provider that the services would be covered. 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 Plan's 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 complete denture - maxillary (D5110) and complete denture - mandibular (D5120) provided December 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gingival irrigation (D4921) for all 4 quadrants. 
 
You asked the Plan to pre-approve the dental services. You say that the services are necessary. The Plan denied 
your request. The Plan says gingival irrigation is not listed as a covered service. 
 
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 gingival irrigation not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
gingival irrigation (D4921) for all 4 quadrants.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on December 9, 2021. 
 
You asked the Plan to pay for the dental service. You say that you thought this would be covered by your $500 
dental benefit. The Plan denied your request. The Plan says the frequency limit has been exceeded. 
 
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 and 1 complete series x-ray or 
panoramic x-ray in a 5 year period, the frequency limit has been exceeded. The record shows that the Plan paid 
for a complete series x-ray that you received on June 2, 2021. Therefore, we decided that the Plan does not 
have to pay for the panoramic x-ray (D0330) provided on December 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prefabricated abutments (D6056) and abutment 
supported crowns (D6060) for teeth # 25 and 27. 
 
You asked the Plan to pre-approve the dental services. You say that the existing implants need to be restored 
with abutment and crown. You say that implants er previously approved in 2021. You also say that the enrollee 
does not have finances to pay out of pocket for these services. The Plan denied your request. The Plan says 
dental implants and all associated services are not covered. 
 
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 implant related services 
are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-
approve prefabricated abutments (D6056) and abutment supported crowns (D6060) for teeth # 25 and 27.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 46 additional doses of Feraheme. 
 
You asked the Plan to pre-approve Feraheme. You say that the enrollee has iron deficiency anemia. The Plan 
denied your request. The Plan says the denial of authorization for this drug is correct, because the requested 
dosage is well above the normal amount administered during a one-year period and does not ensure that the 
enrollee will receive the standard therapy. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Feraheme. Our reviewer says that the 
enrollee does not meet the Medicare criteria for the requested dosage of Feraheme. Our physician reviewer 
found the enrollee has a diagnosis of iron deficiency anemia unresponsive to oral iron. The Food & Drug 
Administration (FDA) has stated that Feraheme is indicated for this condition. The record indicates that the enrollee required two doses of Feraheme in April 2021 for the same diagnosis. The record does not support the 
medical necessity of the requested dosage of Feraheme. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Feraheme have not been met. Therefore, we decided that the Plan does not have 
to pre-approve 46 additional doses of Feraheme.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) and 
intraoral - periapical first radiographic image (D0220) provided November 30, 2021. 
 
You asked the Plan to pay for the limited oral exam and intraoral x-ray. You say that these services were 
necessary, and you were dissatisfied with services received earlier in the year. The Plan denied your request. 
The Plan says you have exhausted your annual dental allowance. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the limited 
oral exam and intraoral x-ray up to your $1,000 annual maximum.  
 
We looked at the file and Medicare rules. The Plan provided documentation showing that your $1,000 annual 
dental allowance has been exhausted for 2021. Therefore, we decided that the Plan does not have to pay for the 
limited oral evaluation - problem focused (D0140) and intraoral - periapical first radiographic image (D0220) 
provided November 30, 2021.  
Your complaint about feeling that the Plan did not adequately help you resolve your issues with a previous 
dentist and concerns with the Plan's customer service system are not valid appeals for medical coverage. This 
part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the endodontic therapy, anterior tooth (excluding final 
restoration) (D3310) provided November 8, 2021. 
 
You asked the Plan to pay for the root canal. You say that a root canal should be covered as a preventative 
procedure. 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 Plan's 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 
endodontic therapy, anterior tooth (excluding final restoration) (D3310) provided November 8, 2021.  
Your complaint about the Plan's care priorities and feeling that the dental plan provides inadequate coverage is 
not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by 
the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services (99152) provided on August 
26, 2021, and August 27, 2021. 
 
You asked the Plan to pay for code 99152. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered. 
 
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, the CPT Code Manual definition of code 99152 is Moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older. 
 
We find that CPT code 99152 is not supported in the medical record. Specifically, the medical record does not 
contain evidence that moderate sedation was performed with the presence of an independent trained observer. 
Based on this information, we decided that Medicare rules for coverage of code 99152 have not been met. 
Therefore, we decided that the Plan does not have to pay for the moderate sedation services (99152) provided 
on August 26, 2021, and August 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power seat elevation system (E2300) wheelchair 
component or accessory, not otherwise specified, base wedge (K0108). 
 
You asked the Plan to pre-approve the wheelchair accessories. You say that you are appealing the decision of 
denial for the enrollee's wheelchair and the seating functions. He currently has a power wheelchair and you are 
requesting an identical properly functioning power wheelchair. The Plan denied your request. The Plan says a 
power seating system does not serve a primary purpose and wheelchair seat and back cushion codes are all-
inclusive. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. A power seating system does not serve a primary purpose and the 
use of HCPCS code K0108 or any other HCPCS code to separately bill for added components such as the foam 
blocks, gel packs, air cells, or equivalent material is incorrect coding. Based on this information, we decided 
that Medicare rules for coverage of the wheelchair accessories have not been met. Therefore, we decided that 
the Plan does not have to pre-approve power seat elevation system (E2300) wheelchair component or 
accessory, not otherwise specified, base wedge (K0108).
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the abutment supported crowns (D6058) and bone graft (D6104). 
We decided that the Plan does not have to pre-approve second stage implant surgery (D6011).  
 
You asked the Plan to pre-approve the dental services. You say these services are medically necessary, and the 
implants are requested as an attachment for the denture. The Plan says that the requested treatment conflicts 
with another treatment which has already been approved 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. 
 
We decided that the Plan has to pre-approve the abutment supported crowns (D6058) and bone graft 
(D6104).  
 
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 the abutment supported crowns 
(D6058) and bone graft (D6104). Our reviewer says that the requested services are appropriate in this case. Our 
physician reviewer found that based on the documentation provided, placement of implant supported crowns in 
the area of teeth #6 and #12 is medically reasonable and necessary due to the lack of adequate abutment teeth 
to support a partial denture. The requested treatment is not in conflict with the previously approved services of 
a partial upper denture and extractions of teeth #6 and #12.  
 
We looked at this physician's review, the file, and the Plans rules. Our physician reviewer states that there is 
no conflict between these services and those previously approved by the Plan. In addition, the limitations listed 
in the contract do not exclude these services from coverage based on the previously approved services. Based 
on this information, we decided that Medicare rules for coverage of the abutment supported crowns (D6058) 
and bone graft (D6104) have been met. Therefore, we decided that the Plan has to pre-approve the abutment 
supported crowns (D6058) for teeth #6 and #12 and bone graft (D6104) for tooth #12.  
 
We also decided that the Plan does not have to pre-approve second stage implant surgery (D6011). 
 
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 
second stage implant surgery (D6011) for teeth #6 and #12. 
 
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 pre-approve a bone graft at time of implant placement (D6104) and 
osseous, osteoperiosteal, or cartilage graft (D7950). 
 
You asked the Plan to pre-approve the bone graft and osseous, osteoperiosteal, or cartilage graft. You say that it 
is very important to have this work done since it is related to your oral health. You also say that if you do not 
receive these services, you cannot continue to the next step because without a strong base the implant cannot be 
placed. The Plan denied your request. The Plan says these services are not covered. 
 
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 
bone graft at time of implant placement (D6104) and osseous, osteoperiosteal, or cartilage graft (D7950).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an occlusal orthotic device for treatment of 
temporomandibular joint (TMJ) dysfunction (D7880). 
 
You asked the Plan to pre-approve the dental item. You say that your diagnosis related to your masseter 
muscle. You also say this should be covered. The Plan denied your request. The Plan says oral appliance is not 
a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested occlusal device is not 
among those covered under this benefit. Additionally, the dental item you are asking the Plan to pre-approve 
involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting 
your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that 
the Plan does not have to pre-approve an occlusal orthotic device for treatment of temporomandibular joint 
(TMJ) dysfunction (D7880).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the crown (D2740) and prefabricated post and core in 
addition to crown (D2954) provided on May 25, 2021. 
 
You asked the Plan to pay more for the crown and prefabricated post and core. You say that you would like to 
appeal these services. The Plan denied your request. The Plan says the cost share for these services was applied 
correctly per your plan benefits. The Plan also says that cost-sharing is a contractual obligation of the Plan and 
cannot be waived. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, you are responsible for a 50% 
coinsurance for the crown (D2740) and prefabricated post and core in addition to crown (D2954). Therefore, 
we decided that the Plan does not have to pay more for the crown (D2740) and prefabricated post and core in 
addition to crown (D2954) provided on May 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a radiographic/surgical implant index (D6190) and 
surgical placement of implant body: endosteal implant (D6010). 
 
You asked the Plan to pre-approve the radiographic/surgical implant index and endosteal implant. You say that 
when you signed up under this plan your insurance agent told you that the implant would be covered. The Plan 
denied your request. The Plan says the radiographic/surgical implant index is not a covered benefit under the 
dental plan. The Plan also says that the endosteal implant to replace a tooth that was missing prior to the 
effective date of coverage under this plan is not covered because you have not been active under this plan for 
24 consecutive months. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
Though the Plan offers a dental benefit in excess of Medicare coverage, radiographic/surgical implant index 
(D6190) is not among those covered under this benefit. The contract says that waiting periods apply to implants 
for teeth that were missing prior to dental coverage under the Plan: Members must be enrolled in the Plan for 
twenty-four (24) consecutive months before plan coverage applies for these teeth. You became active under 
this plan as of October 1, 2021. The record shows that tooth #14 was extracted on November 17, 2014. 
Therefore, the implant on tooth #14 does not qualify for benefits and remains denied due to the tooth was 
extracted prior to the effective date of coverage under this plan and because you have not been active under this 
plan for twenty-four (24) consecutive months. Therefore, we decided that the Plan does not have to pre-
approve a radiographic/surgical implant index (D6190) and surgical placement of implant body: endosteal 
implant (D6010).