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

 
We decided that the Plan does not have to pay for the re-cement or re-bond crown (D2920) provided on March 14, 2022. 
 
You asked the Plan to pay for the re-cement or re-bond crown. You say that you believed this service would be 
covered. 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 re-
cement or re-bond crown (D2920) provided on March 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and 
first intraoral periapical x-ray (D0220) provided on April 6, 2022. 
 
You asked the Plan to pay for the problem focused limited oral evaluation and first intraoral periapical x-ray. 
You say that the exam and x-ray were necessary to determine the extent of the problem. The Plan denied your 
request. The Plan says problem focused limited oral evaluation is not a covered expense under your dental plan. 
The Plan also says that your benefits for the first intraoral periapical x-ray have been satisfied and the 
frequency limitation 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, problem focused limited oral 
evaluation (D0140) is not among those covered under this benefit. The contract says that intraoral x-rays are 
limited to 1 procedure code per calendar year. The record shows that you received a first intraoral periapical x-
ray (D0220) on March 18, 2022 and your intraoral x-rays benefit has been exhausted. Therefore, we decided 
that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and first intraoral 
periapical x-ray (D0220) provided on April 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown a tooth #10 (D2751). 
 
You asked the Plan to pre-approve the dental services. You say that you disagree with the denial of dental 
services. The Plan denied your request. The Plan says your benefit for the requested item or service has already 
been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service November 26, 2021. 
Therefore, we decided that the Plan does not have to pre-approve a crown a tooth #10 (D2751).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete maxillary denture (D5110) and an immediate 
mandibular denture (D5140), provided by a participating provider on March 30, 2022. 
 
You asked the Plan to pay for a complete maxillary denture and an immediate mandibular denture. You say 
that your current dentures are worn done. The Plan denied your request. The Plan says the rendered dental 
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 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 a 
complete maxillary denture (D5110) and an immediate mandibular denture (D5140), provided by a 
participating provider on March 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services provided by a participating provider. 
 
You asked the Plan to pre-approve dental services. You say that you would like the Plan to pay for this. The 
Plan denied your request. The Plan says these services have been correctly denied. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services 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 dental services 
provided by a participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional supplies, materials, and clinical staff time (99072) 
provided on October 13, 2021. 
 
You asked the Plan to pay for additional supplies, materials, and clinical staff time (99072). You say that the 
documents required to reprocess the underpaid claim are attached. You say that you expect 30% payment from 
the billed charges. The Plan denied your request. The Plan says bundled services are not eligible for separate 
payment. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99072 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99072 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of additional supplies, materials, and clinical staff time (99072) have not been met. Therefore, we decided that 
the Plan does not have to pay for additional supplies, materials, and clinical staff time (99072) provided on 
October 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical placement of implant body: endosteal implant 
(D6010), custom fabricated abutment (D6057), and abutment supported porcelain fused to metal crown 
(D6059). 
 
You asked the Plan to pre-approve an endosteal implant, custom fabricated abutment, and abutment supported 
porcelain fused to metal crown. The Plan denied your request. The Plan says these services are not covered 
under your benefit plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
surgical placement of implant body: endosteal implant (D6010), custom fabricated abutment (D6057), and 
abutment supported porcelain fused to metal crown (D6059).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gingival irrigation  per quadrant (D4921). 
 
You asked the Plan to pay for gingival irrigation. You say that you don't understand why this service is not 
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 gingival 
irrigation  per quadrant (D4921).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on August 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 were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on August 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) provided by a 
periodontist. 
 
You asked the Plan to pre-approve a comprehensive oral evaluation. You say that you were referred to a 
periodontist due to bone loss. The Plan denied your request. The Plan says services must be provided by a 
general dentist. 
 
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 when the services are provided by a participating general dentist.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a comprehensive oral evaluation have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a comprehensive oral evaluation (D0150) provided by a periodontist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve therapeutic parenteral drug (D9610) and removal of 
impacted tooth #29 (D7240). 
 
You asked the Plan to pre-approve the dental services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says therapeutic parenteral drug (D9610) and removal of impacted tooth 
(D7240) are not covered by your routine dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
therapeutic parenteral drug (D9610) and removal of impacted tooth #29 (D7240).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341) provided 
by an out-of-network provider. 
 
You asked the Plan to pre-approve the dental services. You say that these services are medically necessary. 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 Plan has 
approved two of the requested four periodontal scaling and root planing. Therefore, we decided that the Plan 
does not have to pre-approve two of the periodontal scaling and root planing (D4341) provided by an out-of-
network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a retainer crown on tooth #10 and 12 (D6751) and pontic on 
tooth #11 (D6241) provided on February 24, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says a retainer crown (D6751) and pontic (D6241) are not covered by 
your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a retainer 
crown on tooth #10 and 12 (D6751) and pontic on tooth #11 (D6241) provided on February 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an occusal guard (D9944). 
 
You asked the Plan to pre-approve an occusal guard. You say that you disagree with the denial of dental 
services. The Plan denied your request. The Plan says an occusal guard (D9944) is not covered by your dental 
benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
occusal guard (D9944).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown - porcelain/ceramic (D2740), core buildup, 
including any pins when required (D2950), and endodontic therapy, molar tooth (excluding final restoration) 
(D3330). 
 
You asked the Plan to pre-approve a crown, core buildup and root canal. You say that you are in pain, and 
these services are necessary. 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 pre-approve a 
crown - porcelain/ceramic (D2740), core buildup, including any pins when required (D2950), and endodontic 
therapy, molar tooth (excluding final restoration) (D3330).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and intraoral x-rays 
(D0220, D0230) provided on April 4, 2022. 
 
You asked the Plan to pay for an evaluation and x-rays. You say that you should have been told the x-rays were 
not covered before they were taken. The Plan denied your request. The Plan says a limited oral evaluation 
(D0140) and intraoral x-rays (D0220, D0230) are not covered by your 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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a limited 
oral evaluation (D0140) and intraoral x-rays (D0220, D0230) provided on April 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on October 5, 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 were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on October 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical extractions (D7210 x 2), and tumor removal 
(D7410) provided on January 10, 2022. 
 
You asked the Plan to pay for the dental services. You say that there were no in network providers available. 
You say that this was an emergency. You also say that you had no other choice at the time of severe acute pain. 
The Plan denied your request. The Plan says the dental services you received are not listed as 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 dental services are not among those 
covered under this benefit regardless of the provider's network status. Therefore, we decided that the Plan does 
not have to pay for the surgical extractions (D7210 x 2), and tumor removal (D7410) provided on January 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2750) and a core build-up (D2950), provided 
by a participating provider. 
 
You asked the Plan to pre-approve a crown and a core build-up. You say that these crowns are needed because 
you need to replace the missing teeth. The Plan denied your request. The Plan says the requested services are 
not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
crown (D2750) and a core build-up (D2950), provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gingival irrigation (D4921 x 4) provided on March 10, 2022. 
 
You asked the Plan to pay for the gingival irrigation. You say that the services should be covered. 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the gingival irrigation is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the gingival 
irrigation (D4921 x 4) provided on March 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bone replacement graft (code D4263) and surgical 
placement, transosteal implant (code D6050) provided on January 19, 2022. 
 
You asked the Plan to pay for the graft and implant. You say that the bone grafting was medically necessary for 
the success of the implants. The Plan denied your request. The Plan says treatment, removal, or replacement of 
teeth or structures directly supporting teeth, is excluded from coverage. 
 
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 bone replacement graft (code 
D4263) and surgical placement, transosteal implant (code D6050) provided on January 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone grafts at time of implant placement (D6104). 
 
You asked the Plan to pre-approve bone grafts. You say that this service is medically necessary. The Plan 
denied your request. The Plan says bone grafts 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 pre-approve bone 
grafts at time of implant placement (D6104).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213), a crown on tooth 
#12, 13, 14, 15, and 16 (D6750), and a pontic on tooth #14 and 15 (D6240). 
 
You asked the Plan to pre-approve the dental services. You say that you disagree with the denial of dental 
services. The Plan denied your request. The Plan says a maxillary partial denture (D5213), crowns (D6750), 
and pontics (D6240) are not covered by your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
maxillary partial denture (D5213), a crown on tooth #12, 13, 14, 15, and 16 (D6750), and a pontic on tooth #14 
and 15 (D6240).