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

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on July 15, 2022. 
 
You asked the Plan to pay for an evaluation. You say that you were told the extraction would be covered at 
50%. The Plan denied your request. The Plan says a limited oral evaluation (D0140) is not covered by the 
enrollee's supplemental 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, a limited oral evaluation is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a limited oral 
evaluation (D0140) provided on July 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous passive motion exercise device for use on 
knee only (E0935) provided March 10, 2022, to March 23, 2022. 
 
You asked the Plan to pay for the CPM device. You say that kindly find attached all supporting documents 
requested and process the claim for payment. The Plan denied your request. The Plan says this service requires 
that a qualifying service/procedure be received and covered. 
 
The Plan must follow Medicare rules. The rules say that CPM devices are covered only if use of the device 
began within two days of receiving total knee replacement surgery.  
 
Records show that total knee replacement surgery was received on January 4, 2022. Use of a CPM device did not begin until March 23, 2022. This means that use of a CPM device did not start until more than two days 
had elapsed following total knee replacement surgery. Therefore, we decided that the Plan does not have to pay 
for the continuous passive motion exercise device for use on knee only (E0935) provided March 10, 2022, to 
March 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on August 17, 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 August 17, 2022. 
Therefore, we decided that the Plan does not have to pay for the dental services on August 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an addition, endoskeletal system, below knee, flexible 
protective outer surface covering system (L5962) and an all-lower extremity prosthesis, multi-axial rotation 
unit (L5986). 
 
You asked the Plan to pre-approve leg prosthetics. You say that you disagree with the denial as you have had 
volume change which requires a new socket replacement. The Plan denied your request. The Plan says records 
provided do not indicate that you are exposed to harsh conditions or engage in extraordinary activities that 
require extra protection from a specialized prosthetic cover. The Plan also says the multi-axial unit does not 
represent a complete foot. It is part of a foot that must be paired with a complete foot. The vendor indicates that 
you are a K3 ambulator. This is not supported by the medical records provided. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 leg prosthetics. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found you do not walk in a harsh environment, so the protective surface covering system is not 
necessary to protect the prosthesis. The record is very clear you are able to walk with an assistive device at the 
K2 level. The advanced device for the foot is not necessary to support your limited community ambulation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of leg prosthetics have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an addition, endoskeletal system, below knee, flexible protective outer surface covering 
system (L5962) and an all-lower extremity prosthesis, multi-axial rotation unit (L5986).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided by an out-of-network provider 
from April 22, 2021, to December 13, 2021. 
 
You asked the Plan to pay for the dental services. You say that you should be reimbursed $1,000 for 2021. 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. The record shows the provider has opted-out of Medicare. Therefore, we decided that the Plan does not have to pay for the dental services provided by an out-
of-network provider from April 22, 2021, to December 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services (D0230, D0367 and D0350) on August 
10, 2022. 
 
You asked the Plan to pay for the dental services (D0230, D0367 and D0350). You say that you would like to 
request reconsideration of the denied claim. The Plan denied your request. The Plan says the dental services 
(D0367 and D0350) are not covered services.  While the member had already received the allowed frequency 
of dental service (D0230). 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental 
services (D0230, D0367 and D0350) on August 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an amalgam and endodontic therapy services (D2140, 
D3330) provided on July 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. 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 an amalgam and endodontic therapy services (D2140, D3330) provided on July 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided an out-of-
network provider on June 30, 2022. 
 
You asked the Plan to pay for the dental services. You say that these services were medically necessary. 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 a limited oral evaluation (D0140) provided by an out-of-network provider on June 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a crown (D2751) July 20, 2022 
 
You asked the Plan to waive the coinsurance for the crown. You say that the services should be covered as you 
disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied correctly based 
on the services provided. 
 
  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.   
 
You have been asked to pay a 50% coinsurance ($855) for a dental crown (D2751). 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 waive the coinsurance for a crown 
(D2751) July 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on July 
21, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. 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 06/06/2022. Therefore, 
we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on July 
21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental fillings (D2391) provided on August 31, 2022 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. 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 18, 2022. 
Therefore, we decided that the Plan does not have to pay for dental fillings (D2391) provided on August 31, 
2022
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an endodontic therapy (D3330), a pulp cap (D3110), and a 
protective restoration (D2940) provided by an out-of-network provider on June 8, 2022, to July 8, 2022. 
 
You asked the Plan to pay for an endodontic therapy, a pulp cap, and a protective restoration. You say that the 
work done on your molar was essential for chewing. The Plan denied your request. The Plan says the rendered 
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 pay for an 
endodontic therapy (D3330), a pulp cap (D3110), and a protective restoration (D2940) provided by an out-of-
network provider on June 8, 2022, to July 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive oral evaluation- new/established patient 
(D0150) and intraoral-complete series of radiographic images (D0210) provided on July 29, 2022. 
 
You asked the Plan to pay for the dental services. You say that you assumed the provider's office would 
schedule the appropriate time 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 comprehensive oral evaluation- new/established patient (D0150) and 
intraoral-complete series of radiographic images (D0210) was exhausted on date of service June 9, 2021. 
Therefore, we decided that the Plan does not have to pay for comprehensive oral evaluation- new/established 
patient (D0150) and intraoral-complete series of radiographic images (D0210) provided on July 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on August 30, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the services are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental 
services on August 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740) provided on July 20, 2022 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. 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 a crown (D2740) provided on July 20, 2022
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for abutment supported porcelain fused to metal crown (high 
noble metal) (D6059) provided on May 20, 2022. 
 
You asked the Plan to pay for abutment supported porcelain fused to metal crown. You say that this service 
should 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 abutment 
supported porcelain fused to metal crown (high noble metal) (D6059) provided on May 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220), additional 
intraoral periapical x-ray (D0230), panoramic x-ray (D0330), and caries risk assessment and documentation 
(D0603) provided on June 7, 2022. 
 
You asked the Plan to pay for the intraoral periapical x-rays, panoramic x-ray, and caries risk assessment and 
documentation. You say that you contacted the Plan to verify benefits prior to going to the dentist. You also say 
that you were advised x-rays would be no cost to you. The Plan denied your request. The Plan says these 
services are not covered expenses under your dental plan. The Plan also says that you contacted the Plan to 
verify provider eligibility, but no benefits were verified during this call.  
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 first 
intraoral periapical x-ray (D0220), additional intraoral periapical x-ray (D0230), panoramic x-ray (D0330), and 
caries risk assessment and documentation (D0603) provided on June 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140), the first periapical x-ray 
(D0220), the endodontic therapy (D3330), the core build-up (D2950), the crown (D2740), the comprehensive 
oral evaluation (D0150), and the complete series of x-rays (D0210) provided on September 29, 2021, through 
November 24, 2021. 
 
You asked the Plan to pay for the limited oral evaluation (D0140), the first periapical x-ray (D0220), the 
endodontic therapy (D3330), the core build-up (D2950), the crown (D2740), the comprehensive oral evaluation 
(D0150), and the complete series of x-rays (D0210). You say that you cannot afford to pay for the non-covered 
services. The Plan denied your request. The Plan says the 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 pay for the 
limited oral evaluation (D0140), the first periapical x-ray (D0220), the endodontic therapy (D3330), the core 
build-up (D2950), the crown (D2740), the comprehensive oral evaluation (D0150), and the complete series of 
x-rays (D0210) provided on September 29, 2021, through November 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for the crown - porcelain/ceramic 
(D2740) provided on April 18, 2022. 
 
You asked the Plan to provide additional payment for the crown. You say that you and dissatisfied with your 
crown. The Plan denied your request. The Plan says the cost-sharing has been applied 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. The Plan covers the crown 
with 50% coinsurance. 
 
We looked at the file and Medicare rules. You have been asked to pay a total of $334.63 for the crown 
($669.25 allowed amount x 50% coinsurance = $334.63). This means you have been asked to pay the correct 
amount based on your contract with the Plan. Therefore, we decided that the Plan does not have to provide 
additional payment for the crown - porcelain/ceramic (D2740) provided on April 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prophylaxis (D1110) and a periodic oral examination 
(D0120) provided by an out-of-network provider on July 12, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for these 
services. 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 prophylaxis (D1110) and a periodic oral examination (D0120) provided an out-of-network provider 
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 by a participating 
provider on August 2, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are trying to find a dentist who can repair 
your denture. 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 5, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided by a 
participating provider on August 2, 2022.