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 prophylaxis (D1110) provided 
on December 15, 2021. 
 
You asked the Plan to pay for the dental services. You say that your dental services have never been denied. 
The Plan denied your request. The Plan says the annual allowance of $1,500 has been exhausted. 
 
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, 
the annual allowance of $1,500 has been exhausted. The record shows that the Plan paid $854 for services 
received on July 12, 2021, $242 for services received on June 8, 2021, $308 for services received on March 3, 2021, and $96 for services received on February 2, 2021. $854 + $242 + 308 + 96 = $1,500. Therefore, we decided that the Plan does not have to pay for the oral exam (D0120), and prophylaxis (D1110) provided on December 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gingival irrigation (D4921). 
 
You asked the Plan to pre-approve the dental service. You say that you have gingivitis. You also say that you 
need the treatment before any other treatments can be done. The Plan denied your request. The Plan says 
gingival irrigation is not listed as a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested gingival irrigation is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
gingival irrigation (D4921).
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for the resin-based composite of one surface (D2391) and two resin-based 
composites of three surfaces (D2393 x2). We decided that the Plan does not have to pay for the gingivectomy 
or gingivoplasty (D4212).  
 
You asked the Plan to pay for the gingivectomy or gingivoplasty (D4212), resin-based composite of one 
surface (D2391), and two resin-based composites of three surfaces (D2393 x2) provided on November 17, 
2020. You say that you would like these services to be covered. The Plan says that the gingivectomy or 
gingivoplasty is not a covered service. The Plan also says that you are limited to 2 resin-based composites in a 
consecutive 12-month period. 
 
We decided that the Plan has to pay for the resin-based composite of one surface (D2391) and two resin-
based composites of three surfaces (D2393 x2).  
 
The Plan follows Medicare rules. Medicare rules say that the health plan must provide you with a clear and 
accurate description of the Original Medicare and/or mandatory/optional supplemental benefits offered under 
your plan contract including applicable conditions and limitations and any other conditions associated with the 
use or receipt of the benefits.  
 
The record shows that you received a resin-based composite (D2393) on the distal, facial or labial, and lingual 
surfaces of tooth #21, a resin-based composite (D2393) on the distal, mesial, and facial or labial surfaces of 
tooth #3, and a resin-based composite (D2391) on the facial or labial surface of tooth #4. The 2020 Evidence of 
Coverage (EOC) states that you are allowed 2 fillings per surface per tooth per 12-month period. The 2020 
EOC does not specifically state that you are only limited to two fillings per calendar year. The provided 
documentation does not show that you have exhausted your fillings benefits of 2 fillings per surface per tooth 
per 12-month period for tooth #'s 3, 4, and 21. Therefore, we decided that the Plan has to pay for the resin-
based composite of one surface (D2391) and two resin-based composites of three surfaces (D2393 x2).  
 
We also decided that the Plan does not have to pay for the gingivectomy or gingivoplasty (D4212). 
 
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 
gingivectomy or gingivoplasty (D4212). 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the local anesthesia in conjunction with operative or surgical 
procedures (D9215) provided on November 12, 2021. 
 
You asked the Plan to pay for the local anesthesia. You say that your tooth broke. You say that you were 
informed that it was infected. You say that you consider this to be an emergency circumstance. You also say 
that some of this may fall under your medical coverage. The Plan denied your request. The Plan says local 
anesthesia in conjunction with operative or surgical procedures is not a covered service. Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the local anesthesia is not among those 
covered under this benefit. Additionally, 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 local anesthesia in conjunction with operative or surgical procedures (D9215) provided on 
November 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical reduction of fibrous tuberosity (D7972). 
 
You asked the Plan to pre-approve the dental service. You say that this service is necessary for the enrollee to 
be fitted for dentures in the future. The Plan denied your request. The Plan says this service is not covered by 
the Plan's dental 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 pre-approve 
surgical reduction of fibrous tuberosity (D7972).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin composite (D2392 and D2391), provided on March 
30, 2021, and April 15, 2021. 
 
You asked the Plan to pay for the resin composites. You say that the services should be covered. The Plan 
denied your request. The Plan says the payment was applied correctly. 
 
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 resin 
composite (D2392 and D2391), provided on March 30, 2021, and April 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the simple extractions (D7140) and mandibular immediate 
denture (D5140), or pay more for the panoramic x-ray (D0330), and maxillary immediate denture (D5130) 
provided from July 23, 2021, to October 12, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the simple extractions and mandibular immediate denture, and to pay more for 
the panoramic x-ray, and maxillary immediate denture. You say that you would like to know why these 
services were denied. The Plan denied your request. The Plan says these services were rendered by an OON 
provider, and OON providers have not agreed to provide services at contracted fees. If you see an OON dentist, 
the coinsurance level will apply to the average negotiated in-network fee schedule (INFS) in your area. You are 
responsible for the difference between the INFS and dentists' charged fees when visiting an OON dentist. The 
Plan also says that you have reached your annual dental maximum of $1,000. 
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 Plan offers a $1,000 annual dental 
benefit maximum. The record shows that you met the annual maximum benefit on October 12, 2021 and your 
annual maximum benefit has been exhausted. You are also responsible for 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 simple extractions (D7140) and mandibular immediate denture (D5140), or pay 
more for the panoramic x-ray (D0330), and maxillary immediate denture (D5130) provided from July 23, 2021, 
to October 12, 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 oral exam (D0120), prophylaxis (D1110), and bitewing 
x-rays (D0272) provided on December 7, 2021. 
 
You asked the Plan to pay for the dental services. You say that at least part of this bill should be paid. You say 
that you had no idea that the provider was out of network. You also say that you never would have thought of 
going there if you knew this ahead of time. The Plan denied your request. The Plan says dental services are 
only covered if received by a participating provider. The Plan also says that dental services received out of 
network are not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
Though the Plan offers a dental benefit in excess of Medicare coverage and the services are listed as covered, 
dental services received out of network are not among those covered under this benefit. Therefore, we decided 
that the Plan does not have to pay for the oral exam (D0120), prophylaxis (D1110), and bitewing x-rays 
(D0272) provided on December 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis (D1110) provided on November 23, 2021. 
 
You asked the Plan to pay for the dental service. You say that you need a cleaning at least 3 times per year. 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 prophylaxis is listed as covered 
service, the frequency limit of twice per calendar year has been exceeded. The record shows that the Plan paid 
for prophylaxis that you received on February 9, 2021, to May 11, 2021. Therefore, we decided that the Plan 
does not have to pay for the prophylaxis (D1110) provided on November 23, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided August 30, 
2021 to September 22, 2021. 
 
You asked the Plan to pay for the SNF services. You say that you feel that the Plan should cover for the SNF 
services provided. The Plan denied your request. The Plan says medical necessity cannot be established for 
SNF level of coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 pay for the SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
service needs. The enrollee does have skilled therapy service needs but does not require skilled therapy on a 
daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in 
a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the SNF services have not been met. Therefore, we decided that the Plan does 
not have to pay for skilled nursing facility (SNF) services provided August 30, 2021 to September 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220) and three 
additional intraoral periapical x-rays (D0230 x3) provided on October 1, 2021. 
 
You asked the Plan to pay for the intraoral periapical x-rays. You say that your primary care physician told you 
to go to the dentist and you thought these services would be covered. The Plan denied your request. The Plan 
says these services are not covered expenses 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 first 
intraoral periapical x-ray (D0220) and three additional intraoral periapical x-rays (D0230 x3) provided on 
October 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for panoramic dental x-rays you received on November 15, 2021. 
 
You asked the Plan to pay for the panoramic dental x-rays. You say that you told the dentist that you didn't 
want an x-ray but the dentist insisted that you have one. The Plan denied your request. The Plan says you are 
only entitled to coverage of panoramic dental x-rays once every 5 years.  You already received covered 
panoramic dental x-rays on September 5, 2019, so you were not eligible for more panoramic dental x-rays 
when you received the x-rays in dispute in this appeal. 
 
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's rules say that 
panoramic dental x-rays are only covered once every 5 years.  This is true regardless of the reason for the 
panoramic x-rays. 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 
panoramic dental x-rays you received on November 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), and adult prophylaxis 
(D1110) provided by an out-of-network provider on November 11, 2021. 
 
You asked the Plan to pay for a periodic oral evaluation and adult prophylaxis. You say that you were 
recommended to this oral surgeon. You say that you have an infection in the bone cavity. The Plan denied your 
request. The Plan says the maximum benefit allowance amount of $2,000 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 Plan's coverage rules apply in this case. The Plan covers a limited 
dental benefit up to $2,000.  
 
We looked at the file and Medicare rules. Evidence was provided to show that your dental benefit maximum 
allowance of $2,000 has already been exhausted.  Based on this information, we decided that the Plan's rules for coverage of a periodic oral evaluation and adult prophylaxis have already been met. Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation (D0120), and adult prophylaxis (D1110) provided by an out-of-network provider on November 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral - periapical first radiographic image (D0220) 
provided September 16, 2021. 
 
You asked the Plan to pay for the periapical x-ray. You say that the dentist said the x-ray would be included in 
your insurance. The Plan denied your request. The Plan says this service is not covered under your benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
intraoral - periapical first radiographic image (D0220) provided September 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup (D2950), provided on September 30, 2021. 
 
You asked the Plan to pay for the core buildup. You say that the service is medically necessary. The Plan 
denied your request. The Plan says this 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 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 (D2950), provided on September 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300). 
 
You asked the Plan to pre-approve a power seat elevation system (E2300). You say that you would like the 
Plan to reconsider their denial. The Plan denied your request. The Plan says a power seat elevation system 
(E2300) is statutorily non-covered by Medicare and the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation system (E2300) is 
statutorily non-covered. Based on this information, we decided that Medicare rules for coverage of a power 
seat elevation system (E2300) have not been met. Therefore, we decided that the Plan does not have to pre-
approve a power seat elevation system (E2300).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established 
patient (D0150) and consultation - diagnostic service provided by dentist or physician other than requesting 
dentist or physician (D9310) provided October 21, 2021. 
 
You asked the Plan to pay for the comprehensive oral exam and diagnostic consultation. You say that you 
would like the services covered. The Plan denied your request. The Plan says you have exceeded the frequency 
limit for the comprehensive exam and the consultation is not covered under your benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the 
comprehensive oral exam once every three years. 
 
We looked at the file and Medicare rules. The Plan provided documentation showing that a comprehensive 
exam was previously covered on May 2, 2019. Based on this information, we decided that the Plan's frequency 
limit for coverage of the comprehensive oral exam has been exceeded. Though the Plan offers dental benefits 
in excess of Medicare coverage, the diagnostic consultation is not among those covered services. Therefore, we 
decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established patient 
(D0150) and consultation - diagnostic service provided by dentist or physician other than requesting dentist or 
physician (D9310) provided October 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete upper denture (D5110), surgical extractions 
(D7210 x 10), and simple extraction (D7140) provided from March 11, 2021, to May 14, 2021. 
 
You asked the Plan to pay for the dental services. You say that you have a yearly limit of $1,000 for covered 
dental services. You say that you were advised your benefit will cover your x-ray and upper denture. You say 
that the claim was billed incorrectly. You also say that you are being overcharged. The Plan denied your 
request. The Plan says the claim was 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 and the services are listed as covered, 
the annual maximum benefit of $1,000 has been exhausted. The record shows that the Plan paid $114 for dental services received on March 11, 2021. The record shows that the Plan paid $886 for dental services received on 
May 14, 2021. $114 + $886 = $1,000. Therefore, we decided that the Plan does not have to pay for the 
complete upper denture (D5110), surgical extractions (D7210 x 10), and simple extraction (D7140) provided 
from March 11, 2021, to May 14, 2021.