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

 
We decided that the Plan does not have to pay for the oral exam (D0120) and cleaning (D1110) provided on 
December 9, 2020. 
You asked the Plan to pay for the dental services. You say that you received a request to return $54 for dental 
services you received. You say that you did not know anything about opting out of Medicare. You also say that 
this claim should be reconsidered. The Plan denied your request. The Plan says the provider in this case has 
opted out of Medicare. The Plan also says that payment cannot be made for services rendered by a provider that 
has opted out of Medicare. 
 
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 and the services are listed as covered, 
payment cannot be made to a provider that has opted out of Medicare. Therefore, we decided that the Plan does 
not have to pay for the oral exam (D0120) and cleaning (D1110) provided on December 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis - adult (D1110) provided November 15, 2021. 
 
You asked the Plan to pay for the dental cleaning. You say that you were unaware there was a frequency limit. 
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 dental 
cleaning twice per plan year. 
 
We looked at the file and Medicare rules. The Plan provided documentation showing that dental cleanings were 
previously covered on March 22, 2021, and August 16, 2021. Based on this information, we decided that the 
Plan's frequency limit for coverage of the dental cleaning has been exceeded. Therefore, we decided that the 
Plan does not have to pay for the prophylaxis - adult (D1110) provided November 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the osseous, osteoperiosteal, or cartilage graft (D7950) 
provided on June 25, 2021. 
 
You asked the Plan to pay for the osseous, osteoperiosteal, or cartilage graft. You say that this surgery was 
medically necessary in order to solve your dental problem The Plan denied your request. The Plan says this 
service is not a covered benefit under your dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 
osseous, osteoperiosteal, or cartilage graft (D7950) provided on June 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a period oral evaluation (D0120), intraoral imaging (D0210), 
and prophylaxis (D1110) provided by out-of-network providers on September 8, 2021. 
 
You asked the Plan to pay for a period oral evaluation, intraoral imaging, and prophylaxis. You say that you 
would like the Plan to pay for this. The Plan denied your request. The Plan says the benefit limit for the dental 
work provided 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. The Plan covers a period oral 
evaluation twice every year, intraoral imaging once every three years, and prophylaxis twice every year. We 
looked at the file and Medicare rules. Evidence was provided to show that on March 3, 2021, D0120 and 
D1110 were provided. On May 19, 2021, D0120, D0210, and D1110 were provided. Based on this information, 
we decided that the Plan's rules for coverage of a period oral evaluation, intraoral imaging, and prophylaxis have already been met. Therefore, we decided that the Plan does not have to pay for a period oral evaluation 
(D0120), intraoral imaging (D0210), and prophylaxis (D1110) provided by out-of-network providers on 
September 8, 2021.
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 December 7, 2021. 
 
You asked the Plan to pay for the limited oral exam and intraoral x-ray. You say that these services were 
routine, and the enrollee expected them to be covered. The Plan denied your request. The Plan says these 
services were not covered under the enrollees 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 
limited oral evaluation - problem focused (D0140) and intraoral - periapical first radiographic image (D0220) 
provided December 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve rebase complete mandibular denture (D5711). 
 
You asked the Plan to pre-approve the dental service. You say that most likely a code was input incorrectly. 
You say that you are not getting a crown, but a liner on your lower denture. You say that it is moving all over 
the place. You also say that it makes it very difficult for you to eat. The Plan denied your request. The Plan 
says rebase complete mandibular denture 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested rebase complete 
mandibular denture is not among those covered under this benefit. Therefore, we decided that the Plan does not 
have to pre-approve rebase complete mandibular denture (D5711).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the retrograde fillings, per root, (D3430 x 2), and 
apicoectomy (D3425) provided on November 15, 2021. 
 
You asked the Plan to pay for the dental services. You say that the services were necessary to save your tooth. 
You also say that the services stopped the infection from seeping into your upper jaw. The Plan denied your 
request. The Plan says retrograde fillings are not listed as covered. The Plan says that apicoectomy is not listed 
as a covered service either. 
 
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 retrograde fillings and apicoectomy 
are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
the retrograde fillings, per root, (D3430 x 2), and apicoectomy (D3425) provided on November 15, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for immunoassay test for blood fecal (82274) provided on
November 23, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for immunoassay test for blood fecal. You say that the lab work on November 23,
2021, was ordered by the patient's primary care physician (PCP) for screening of colon cancer. The Plan denied
your request. The Plan says this provider is not a network provider with the Plan, and they have also
determined that these services are not urgent or emergent, nor were they approved in advance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for immunoassay test for blood fecal (82274) provided on November 23, 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 limited oral evaluation - problem focused (D0140) 
provided November 23, 2021. 
 
You asked the Plan to pay for the limited oral exam. You say that the service was necessary, and you cannot 
afford it. 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 Plans coverage rules apply in this case. The Plan covers the limited 
oral exam once per plan year. 
 
We looked at the file and Medicare rules. The Plan provided documentation showing that a limited oral exam 
was previously covered on August 18, 2021. Based on this information, we decided that the Plan's frequency 
limit for coverage of the limited oral exam has been exceeded. Therefore, we decided that the Plan does not 
have to pay for the limited oral evaluation - problem focused (D0140) provided November 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), and an intraoral 
image (D0210) provided by a participating provider on November 16, 2021. 
 
You asked the Plan to pay for a comprehensive oral evaluation and intraoral image. You say that you would 
like the Plan to pay for this. The Plan denied your request. The Plan says the benefit limit for these services 
have 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. The Plan covers a 
comprehensive oral evaluation and intraoral image once every three years.  
 
We looked at the file and Medicare rules. Evidence was provided to show that D0150 and D0210 were 
provided on January 10, 2020. Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral evaluation and intraoral image have already been met. Therefore, we decided that the Plan 
does not have to pay for a comprehensive oral evaluation (D0150), and an intraoral image (D0210) provided by 
a participating provider on November 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), and a panoramic 
radiographic image (D0330) provided by a participating provider on December 7, 2021. 
 
You asked the Plan to pay for a comprehensive oral evaluation and a panoramic radiographic image. You say 
that you were having problems with your mouth The Plan denied your request. The Plan says the benefit limit 
for D0150 and D0330 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. The Plan covers a 
comprehensive oral evaluation and a panoramic radiographic image once every three years. 
 
We looked at the file and Medicare rules. Evidence was provided to show that D0150 and D0330 were 
provided on July 22, 2020. Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral evaluation and a panoramic radiographic image have not been met. Therefore, we decided 
that the Plan does not have to pay for a comprehensive oral evaluation (D0150), and a panoramic radiographic 
image (D0330) provided by a participating provider on December 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sedation services provided on February 13, 2021. 
 
You asked the Plan to pay for the services provided. You say that the medical records support the claim. The 
Plan denied your request. The Plan says the billed service cannot be verified. 
 
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.
We find that CPT code 99152 is not supported in the medical record. Specifically, the records provided do not 
indicate sedation services required the presence of an independent trained observer. Based on this information, 
we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided 
that the Plan does not have to pay for the sedation services provided on February 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an interim complete mandibular denture (D5811) provided 
by an out-of-network provider on September 3, 2021. 
 
You asked the Plan to pay for an interim complete mandibular denture. You say that you needed this denture 
because you could feel your depression worsening. The Plan denied your request. The Plan says D5811 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 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 an interim 
complete mandibular denture (D5811) provided by an out-of-network provider on September 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the telehealth services provided on July 26, 
2021, and November 30, 2021. 
 
You asked the Plan to waive the copayment for the telehealth services. You say that you feel the over-the-
phone appointment is not the same as in-person. The Plan denied your request. The Plan says the copayment 
applied is correct. 
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 $15 for 
each covered telehealth visitor consultation in an outpatient location with your PCP.  
 
You have been asked to pay a $15 copay for the telehealth services. The telehealth services fall within the 
"Covered services include" 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 
telehealth services provided on July 26, 2021, and November 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on 
November 5, 2021. 
 
You asked the Plan to pay for the dental service. You say that the dentist you saw previously did nothing to 
address your pain. You also say that you should not have to pay this bill because the provider did not obtain a 
predetermination of coverage for the care you received. 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 comprehensive oral evaluation is 
covered every 3 plan years, the frequency limit has been exceeded. The record shows that the Plan paid for a comprehensive oral evaluation that you received on September 3, 2021. Therefore, we decided that the Plan 
does not have to pay for the comprehensive oral evaluation (D0150) provided on November 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on 
October 11, 2021. 
 
You asked the Plan to pay for the dental service. You say that you feel that your previous dentist was not 
cleaning your teeth well. You say that you found a new dentist. You also say that a new dentist should be able 
to do a thorough exam on your first visit. 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 comprehensive oral evaluation is 
covered every 3 plan years, the frequency limit has been exceeded.  The record shows that the Plan paid for a comprehensive oral evaluation that you received on March 22, 2021. 
Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) 
provided on October 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on June 27, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is 
always bundled into payment for other services not specified. 
 
We looked at the file and Medicare rules. Billed procedure code 92921 (percutaneous transluminal coronary 
angioplasty, each additional branch) has a status indicator of B and no separate Medicare payment. Therefore, 
we decided that the Plan does not have to pay for the surgical services rendered on June 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an occlusal guard  hard appliance, full arch (D9944). 
 
You asked the Plan to pre-approve a mouth guard. You say that you need the mouth guard to prevent further 
damage to your teeth. 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 an 
occlusal guard  hard appliance, full arch (D9944).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) 
provided November 12, 2021. 
 
You asked the Plan to pay for the limited oral exam. You say that you would like 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 limited 
oral exam once every 12 months.  
 
We looked at the file and Medicare rules. The Plan provided documentation showing that a limited oral exam 
was previously covered on September 27, 2021. Based on this information, we decided that the Plan's 
frequency limit for coverage of the limited oral exam has been exceeded. Therefore, we decided that the Plan 
does not have to pay for the limited oral evaluation - problem focused (D0140) provided November 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), and intraoral 
imaging (D0210) provided by a participating provider on October 6, 2021. 
 
You asked the Plan to pay for a comprehensive oral evaluation and intraoral imaging. You say that the dentist 
on the original visit refused to clean your teeth. You say that you had to go back. The Plan denied your request. 
The Plan says the benefit limit of D0150 and D0210 have 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. The Plan covers a 
comprehensive oral evaluation and intraoral imaging when the services are medically necessary and 
reasonable.  
 
We looked at this the file and Medicare rules. Evidence was provided that shows that D0150 and D0210 was 
previously provided on August 18, 2020. Based on this information, we decided that the Plan's rules for 
coverage of a comprehensive oral evaluation and intraoral imaging have not been met. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), and intraoral imaging (D0210) 
provided by a participating provider on October 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis (D1110) provided on November 15, 2021. 
 
You asked the Plan to pay for the prophylaxis. You say that you believe this claim should be approved for 
coverage because you were not correctly informed of the allowed coverage. The Plan denied your request. The 
Plan says cleanings are limited to two visits per calendar year. The Plan also says that you were correctly 
informed by the customer service representative that cleanings are limited to two visits per calendar year. 
 
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, cleanings and are limited to 2 per 
calendar year. The record shows that you received prophylaxes (D1110) on January 26, 2021, and May 25, 
2021 and your cleanings benefit has been exhausted. Therefore, we decided that the Plan does not have to pay 
for the prophylaxis (D1110) provided on November 15, 2021.