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

 
We decided that the Plan does not have to pay for the adjunctive pre-diagnostic testing (D0431), unspecified 
periodontal procedure (D4999 x 4), gingival irrigation (D4921 x 4), localized delivery of antimicrobial agents 
(D4381 x 5), and drugs or medicaments (D9630 x 2) provided from April 14, 2022, to April 18, 2022. 
 
You asked the Plan to pay for the adjunctive pre-diagnostic testing, periodontal services, and drugs or 
medicaments. You say that you feel that the provider's fees to the plan are too high. The Plan denied your request. The Plan says the adjunctive pre-diagnostic testing, unspecified periodontal procedures, gingival 
irrigation, localized delivery of antimicrobial agents, and drugs or medicaments are not listed as covered services. 
 
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. Therefore, we decided that the Plan does not have to pay for the adjunctive pre-
diagnostic testing (D0431), unspecified periodontal procedure (D4999 x 4), gingival irrigation (D4921 x 4), 
localized delivery of antimicrobial agents (D4381 x 5), and drugs or medicaments (D9630 x 2) provided from 
April 14, 2022, to April 18, 2022.  
 
Your complaint about how much the dentist bills for their services is not a valid appeal for medical coverage. 
This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to 
make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and core build up 
(D2950) and pay an additional amount for the periapical x-ray (D0220) provided on March 10, 2022, by the 
out-of-network provider. 
 
You asked the Plan to pay for the dental services. You say that this was an emergent issue with your broken 
tooth. You say that the best course of action was to have a crown placed. You also say that you wanted to save 
the tooth. The Plan denied your request. The Plan says limited oral evaluation and core build up are not listed 
as covered dental services. The Plan also says that out-of-network providers may bill you for any amount 
greater than what the Plan pays the provider. 
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the limited oral evaluation and core 
build up are not among those covered under this benefit. Additionally, out-of-network providers may bill you 
for any amount greater than what the Plan pays the provider. Therefore, we decided that the Plan does not have 
to pay for the limited oral evaluation (D0140) and core build up (D2950) and pay an additional amount for the 
periapical x-ray (D0220) provided on March 10, 2022, by the out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), panoramic 
radiographic imaging (D0330), nutritional counseling (D1310), and oral hygiene instructions (D1330), 
provided by a participating provider April 28, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. 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 March 21, 2022 for D0150 and D0330. Therefore, we decided that the Plan does not have to pay for a comprehensive oral 
evaluation (D0150), panoramic radiographic imaging (D0330), nutritional counseling (D1310), and oral 
hygiene instructions (D1330), provided by a participating provider on April 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a core build-up (D2950) provided by a participating provider 
on February 10, 2022. 
 
You asked the Plan to pay for a core build-up. You say that you pay for dental coverage. You say that this 
should be covered The Plan denied your request. The Plan says the denied dental service is not a covered 
benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a core 
build-up (D2950) provided by a participating provider on February 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve five replacements of replaceable parts of semi-precision 
or precision attachment of implant/abutment supported prosthesis (D6091 x5). 
 
You asked the Plan to pre-approve the replacements of replaceable parts. The Plan denied your request. The 
Plan says this service is not a covered benefit under the enrollee's 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 five 
replacements of replaceable parts of semi-precision or precision attachment of implant/abutment supported 
prosthesis (D6091 x5).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for osseous surgery (D4260, D4261) provided on March 1, 2022. 
 
You asked the Plan to pay for osseous surgery. You say that you thought this service was covered. The Plan 
denied your request. The Plan says osseous surgery (D4260, D4261) 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 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 osseous 
surgery (D4260, D4261) provided on March 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical extractions (D7210) and bone grafts at time of 
implant placement (D6104) provided on February 24, 2022. 
 
You asked the Plan to pay for the surgical extractions and bone grafts. The Plan denied your request. The Plan 
says the annual limit allowed by your dental plan for this benefit year has been paid. 
 
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 $1,500 annual dental 
benefit maximum every year for non-Medicare covered preventive and comprehensive dental services. You are 
responsible for any amount above the dental coverage limit.  
 
The record shows that you met the annual maximum benefit on February 24, 2022, and your annual maximum 
benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the surgical 
extractions (D7210) and bone grafts at time of implant placement (D6104) provided on February 24, 2022.
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 bitewings - four radiographic images (D0274) provided April 19, 2022. 
 
You asked the Plan to pay for the dental services. You say that this exam was required prior to having joint 
replacement. 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 Plan's 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 July 7, 2021.  
 
Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation - new or 
established patient (D0150) and bitewings - four radiographic images (D0274) provided April 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for retainer crowns on tooth #28 and 30 (D6740) and a pontic on 
tooth #29 (D6245) provided on January 11, 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 retainer crowns (D6740) and pontic (D6245) 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 retainer 
crowns on tooth #28 and 30 (D6740) and a pontic on tooth #29 (D6245) provided on January 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the endodontic therapy, molar tooth (excluding final 
restoration) (D3330) provided March 21, 2022, by an out-of-network dentist. 
 
You asked the Plan to pay more for the dental services. You say that you were unable to find a network 
provider who could perform the services. The Plan denied your request. The Plan says you are responsible for 
50% coinsurance and any charged amount above the Plan's cost-sharing amount when your services are 
received from an out-of-network provider. 
 
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. 
 
You have been asked to pay 50% coinsurance plus the difference between the out-of-network provider's 
charges and the Plan's payment. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. The Plan indicates there were no attempts contact the Plan for information about network 
providers who can provide this service. Therefore, we decided that the Plan does not have to pay more for the 
endodontic therapy, molar tooth (excluding final restoration) (D3330) provided March 21, 2022, by an out-of-
network dentist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a gingivectomy (D4212) provided on February 22, 2022. 
 
You asked the Plan to pay for a gingivectomy. You say that you disagree with the denial of dental services. The 
Plan denied your request. The Plan says gingivectomy (D4212) is 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 pay for a 
gingivectomy (D4212) provided on February 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on July 21, 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 the PC and TC for diagnostic services are separately 
payable when furnished in different payment localities. 
 
We looked at the file and Medicare rules. The file shows that the PC and TC were not performed in different 
payment localities. Based on this information, we decided that Medicare rules for coverage of these services 
have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services 
rendered on July 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for the complete series x-ray (D0210) 
provided on April 1, 2022. 
 
You asked the Plan to pay an additional amount for the dental service. You say that you did not get information 
about the deductible. You also say that you did not know about it until you received the bill. The Plan denied 
your request. The Plan says you are responsible for the $100 deductible. The Plan also says you are responsible 
for the 50% coinsurance of $4.50 after the deductible was paid. 
 
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 complete series x-ray is listed as 
covered, there are cost shares that apply. The record shows that the allowed amount for this service is $109. 
$109 - $100 deductible = $9. $9 x 50% coinsurance = $4.50. $100 deductible + $4.50 coinsurance = $104.50. 
Therefore, we decided that the Plan does not have to pay an additional amount for the complete series x-ray 
(D0210) provided on April 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 4, 2021 billed with 
codes 81206, 81292, and 81301. 
 
You asked the Plan to pay for the genetic testing billed. 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 if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
June 4, 2021 billed with codes 81206, 81292, and 81301.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pontics (D6245 x 3), custom fabricated abutments 
(D6057 x 5), and abutment supported crowns (D6068 x 5) provided on October 25, 2021, by the out of network 
provider. 
 
You asked the Plan to pay for the dental services. You say that you do not understand why the services were 
denied. The Plan denied your request. The Plan says the 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the pontics, custom fabricated 
abutments, and abutment supported crowns are not among those covered under this benefit. Additionally, 
dental services received out of network are not covered. Therefore, we decided that the Plan does not have to 
pay for the pontics (D6245 x 3), custom fabricated abutments (D6057 x 5), and abutment supported crowns 
(D6068 x 5) provided on October 25, 2021, by the out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120) provided on April 13, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were not aware that the provider was out-
of-network. 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 Plan's 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 periodic oral evaluation (D0120) provided on April 13, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from July 26, 2022, forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from July 26, 2022, forward. You say that the 
services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are 
not medically necessary. 
 The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care from July 26, 
2022, forward. Our reviewer says that the enrollee does not meet the criteria for acute inpatient mental health 
treatment beyond the date in question of July 26, 2022, forward. Our physician reviewer found the enrollee did 
not require inpatient mental health treatment beyond July 26, 2022, as she was not a danger to herself or others 
and did not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was 
taking place beyond the date in question. It did not appear that the services for the dates in question were 
reasonably expected or medically necessary to improve the enrollees condition or for the purpose of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from July 26, 2022, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from July 26, 2022, 
forward.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core build up on tooth #30 (D2950) provided on March 24, 2022. 
 
You asked the Plan to pay for core build up. You say that the services were medically necessary. The Plan 
denied your request. The Plan says core build up (D2950) is not covered by your supplemental 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 pay for core build 
up on tooth #30 (D2950) provided on March 24, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional routine transportation. You say that the additional transportation 
is necessary. The Plan denied your request. The Plan says the benefit has been exhausted. Therefore, coverage 
criteria have not been met. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 60 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and prophylaxis 
(D1110) provided on October 27, 2021, by the out of network provider. 
 
You asked the Plan to pay for the dental services. You say that the enrollee had to find a new dentist due to 
changes in the plan network. You say that the enrollee has not been able to find a dentist that they like. You 
also say that you would like for this and the next appointment to be covered. The Plan denied your request. The 
Plan says the benefit limit for comprehensive oral evaluation has been exhausted. The Plan says that out of 
network providers may bill you for any amount greater than what the plan pays the provider. 
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and comprehensive oral evaluation is 
listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a 
comprehensive oral evaluation that you received on April 8, 2021. The record shows that the provider in this 
case is out of network. The Evidence of Coverage clearly states that out of network providers may bill you for 
any amount greater than what the plan pays. Therefore, we decided that the Plan does not have to pay for the 
comprehensive oral evaluation (D0150) and prophylaxis (D1110) provided on October 27, 2021, by the out of 
network provider.