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

 
We decided that the Plan does not have to pay for the surgical removal of implant (D6100), guided tissue 
regeneration (D4266), bone replacement graft (D7953), and orthodontic retention (D8680) provided on 
February 24, 2022. 
 
You asked the Plan to pay for the dental services. You say that you needed to see a specialist for an infection in 
your gums that would not clear up. You say that you were not aware that the services would not be covered. 
You also say that this bill would be a financial hardship for you. The Plan denied your request. The Plan says 
the claim denied correctly. 
 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 surgical removal of implant, guided 
tissue regeneration, bone replacement graft, and orthodontic retention are not among those covered under this 
benefit. Therefore, we decided that the Plan does not have to pay for the surgical removal of implant (D6100), 
guided tissue regeneration (D4266), bone replacement graft (D7953), and orthodontic retention (D8680) 
provided on February 24, 2022.
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) for tooth 27 provided January 28, 2022. 
 
You asked the Plan to pay for the root canal. You say that you were unaware that there was a frequency limit 
for this service. The Plan denied your request. The Plan says you have exceeded the frequency limit for this 
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. The Plan covers the root canal 
once per tooth per lifetime. 
 
We looked at the file and Medicare rules. The Plan provided documentation showing that a root canal for tooth 
27 was previously covered on November 17, 2020. Based on this information, we decided that the Plan's 
frequency limit for coverage of the root canal has been exceeded. Therefore, we decided that the Plan does not 
have to pay for the endodontic therapy, anterior tooth (excluding final restoration) (D3310) for tooth 27 
provided January 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950) 
provided January 4, 2022. 
 
You asked the Plan to pay for the core buildup. You say that you were not told prior to the services that this 
service would not be 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 core 
buildup, including any pins when required (D2950) provided January 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown - porcelain/ceramic (D2740) and core buildup, 
including any pins when required (D2950) provided January 12, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the crown and core buildup. You say that you were unable to locate an in-
network provider accepting new patients. Additionally, you feel that core buildup should be billed with the 
crown and not as a separate service. The Plan denied your request. The Plan says the core buildup is not a 
covered service. The crown was processed correctly according to your OON 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 Plan covers the crown with 75% coinsurance when provided OON. You may be billed by the OON provider for any amount greater 
than the payment made by the Plan to the provider. 
 
We looked at the file and Medicare rules. You have been asked to pay 75% of the allowed amount for the 
crown. Additionally, you are responsible for the difference between the Plans allowed amount and the total 
cost charged by the OON provider. Therefore, we decided that the Plan does not have to provide additional 
payment for the crown  porcelain/ceramic (D2740) provided January 12, 2022, by an OON provider. Though 
the Plan offers dental benefits in excess of Medicare coverage, the core buildup is not among those covered 
services. Therefore, we decided that the Plan does not have to pay for the core buildup, including any pins 
when required (D2950) provided January 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the consultation - diagnostic service provided by dentist or 
physician other than requesting dentist or physician (D9310) provided June 11, 2021, and the hospital or 
ambulatory surgical center call (D9420) provided August 25, 2021. 
 You asked the Plan to pay for the dental consultation and hospital or ambulatory surgical center call. You say 
that you were told that you could use an out-of-network provider. 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 pay for the 
consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician 
(D9310) provided June 11, 2021, and the hospital or ambulatory surgical center call (D9420) provided August 
25, 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 November 3, 2021. 
 
You asked the Plan to pay for the upper and lower denture. You say that your employer plan should not have 
terminated until December 31, 2021. The Plan denied your request. The Plan says this service is not covered 
under your dental benefits with your Medicare plan. 
 
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 November 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction (D7140), periapical x-ray (D0220), and 
unspecified preventive service (D1999) provided on February 4, 2022, by the out of network dentist. 
 
You asked the Plan to pay for the dental services. You say that you had to have an emergency tooth extraction. 
You say that you were not aware the provider was out of network. You also say that you were advised by a 
plan representative they would send you a list of in network dentists. The Plan denied your request. The Plan 
says the claim denied correctly. 
 
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 periapical x-ray is covered per 
calendar year, out of network providers may bill you for any amount greater than what the plan pays. 
Additionally, the extraction and unspecified preventive service are not among those covered under this benefit. 
Therefore, we decided that the Plan does not have to pay for the extraction (D7140), periapical x-ray (D0220), 
and unspecified preventive service (D1999) provided on February 4, 2022, by the out of network dentist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for the bitewings - four radiographic 
images (D0274), periodic oral evaluation - established patient (D0120), and prophylaxis - adult (D1110) 
provided February 8, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to provide additional payment for the bitewing x-rays, periodic oral exam and dental 
cleaning. You say that you were misinformed about the providers network status. The Plan denied your 
request. The Plan says these services have processed correctly according to your OON 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 Plan covers the bitewing 
x-rays, periodic oral exam and dental cleaning with 50% coinsurance when provided OON. You may be billed by the OON provider for any amount greater than the payment made by the Plan to the provider. 
 
We looked at the file and Medicare rules. You have been asked to 50% of the allowed amount for these 
services. Additionally, you are being asked to pay the difference between the allowed amount and the total cost 
billed by the OON provider. Therefore, we decided that the Plan does not have to provide additional payment 
for the bitewings - four radiographic images (D0274), periodic oral evaluation - established patient (D0120), 
and prophylaxis - adult (D1110) provided February 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 for custom abutments (D6057 x 2) provided on October 13, 2021. 
 
You asked the Plan to pay for the custom abutments. You say that the services should be covered. The Plan 
denied your request. The Plan says abutments 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, the custom abutments are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for custom 
abutments (D6057 x 2) provided on October 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bone replacement graft for ridge preservation (D7953) 
provided on October 12, 2021. 
 
You asked the Plan to pay for the bone replacement graft. You say that the Plan should have paid for these 
services. The Plan denied your request. The Plan says this service is 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 pay for the bone 
replacement graft for ridge preservation (D7953) provided on October 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical placement of implant body: endosteal implant 
(D6010), bone graft at time of implant placement (D6104), surgical extraction (D7210), and local anesthesia 
(D9215) provided on June 23, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the endosteal implant, bone graft, surgical extraction, and local anesthesia. You 
say that you would like these services to be approved for coverage. The Plan denied your request. The Plan 
says these services were rendered by a provider who is not part of the Plan's network of providers. The Plan 
also says that there was not an authorization or a request for authorization, and the services were not considered 
urgent or emergent in nature. 
 
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 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the surgical 
placement of implant body: endosteal implant (D6010), bone graft at time of implant placement (D6104), 
surgical extraction (D7210), and local anesthesia (D9215) provided on June 23, 2021 by an out-of-network 
(OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the eye exam (92014) provided on January 
5, 2022. 
 
You asked the Plan to waive the copayment for the eye exam. You say that you were careful to use in-network 
providers and feel that the Plan should have been clearer that the routine network for vision care is not the same 
as the medical network. The Plan denied your request. The Plan says this claim was processed correctly, and 
your copayment was assessed in accordance with your contract. 
 
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 $35 
copayment for Medicare-covered vision services provided in a specialist's office.  
 You have been asked to pay a $35 copayment for the eye exam. The claim for the eye exam in this case was 
billed with a medical diagnosis. This means that this eye exam is not considered routine and falls within the 
Medicare-covered vision services provided in a specialists office 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 the eye exam (92014) provided on January 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crowns - porcelain/ceramic (D2740) provided October 
27, 2021. 
 
You asked the Plan to pay for the crowns. You say that this service was not just for cosmetic purposes. The 
Plan denied your request. The Plan says this service is not covered because you do not have dental coverage 
with this plan. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for 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 pay for the crowns - porcelain/ceramic 
(D2740) provided October 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the preventive procedure (D1999) provided on July 10, 2020. 
 
You asked the Plan to pay for the preventive procedure. You say that you only had x-rays done by the dentist 
and not the other services billed. You also say that you were told by the Plan initially that the provider was in-
network. The Plan denied your request. The Plan says this service 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 the 
preventive procedure (D1999) provided on July 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis 
(D1110) provided on February 16, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that you were not aware 
that this treating provider was OON. You also say that you did not receive a provider handbook until after this 
appointment, and the provider never informed you that they were no longer in-network. The Plan denied your 
request. The Plan says you received these services from an OON provider. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, you are responsible for $10 
copayments for each of these services, plus the difference between the billed amount and allowed amount 
because these services were received OON. Therefore, we decided that the Plan does not have to pay for the 
periodic oral evaluation (D0120) and prophylaxis (D1110) provided on February 16, 2022 by an out-of-
network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Wheelchair accessory, power seat elevation system 
(E2300). 
 
You asked the Plan to pre-approve power seat elevation system. You say that please reconsider the 
documentation provided for the wheelchair and accessories that are medically necessary to meet the clients 
current needs. The Plan denied your request. The Plan says the seat elevator does not serve a primary medical 
purpose and is not covered. 
 
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. Based on this information, we decided that Medicare rules for 
coverage of power seat elevation system have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Wheelchair accessory, power seat elevation system (E2300).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140), periapical x-ray 
(D0220), oral exam (D0120), bitewing x-rays (D0274), periodontal maintenance (D4910), and take home drug 
(D9630) provided from February 2, 2021, to February 4, 2021. 
 
You asked the Plan to pay for the dental services. You say that these claims were before the coronavirus. You 
also say that then the claims were processed after they were sent in. The Plan denied your request. The Plan 
says they would maintain our original decision to not pay for services submitted after the 12 month claim 
submission timeframe. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the dental services was not filed until February 10, 2022. This means that 
more than one calendar year from the date of service had passed before a claim was filed.  
 Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140), periapical x-
ray (D0220), oral exam (D0120), bitewing x-rays (D0274), periodontal maintenance (D4910), and take home 
drug (D9630) provided from February 2, 2021, to February 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the post and core in addition to a crown (D2954), root canal 
(D3330), and cone beam computed tomography (CT) (D0364) provided on March 4, 2022. 
 
You asked the Plan to pay for the dental service. You say that the previous dentist you saw misdiagnosed you. 
You say that these services were necessary. You also say that you were on a fixed income. The Plan denied 
your request. The Plan says the claim processed correctly. 
 
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 post and core in addition to a crown, root canal, and cone beam CT are not among those covered under this benefit. Therefore, we decided 
that the Plan does not have to pay for the post and core in addition to a crown (D2954), root canal (D3330), and 
cone beam computed tomography (CT) (D0364) provided on March 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete 
series of intraoral x-rays (D0210) provided on January 19, 2022. 
 
You asked the Plan to pay for the comprehensive oral evaluation and complete series of intraoral x-rays. You 
say that you were not advised that these services would not be covered. You also say that you are on a fixed 
low income and are unable to pay for these services. The Plan denied your request. The Plan says your benefits 
for these services have been satisfied and the frequency limitations have 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, comprehensive oral evaluation 
(D0150) is limited to 1 procedure code every 3 calendar years, and full mouth or panoramic x-rays are limited 
to 1 procedure code every 5 calendar years. The record shows that you received a comprehensive oral 
evaluation (D0150) and complete series of intraoral x-rays (D0210) on January 27, 2021 and your 
comprehensive oral evaluation (D0150) and full mouth or panoramic x-rays benefits have been exhausted. 
Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and 
complete series of intraoral x-rays (D0210) provided on January 19, 2022.