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

 
We decided that the Plan does not have to reimburse you for the oral exam (D0120), prophylaxis (D1110 x 3), 
and bitewing x-rays (D0274) provided from August 4, 2020, to September 7, 2021. 
 
You asked the Plan to reimburse you for the dental services. You say that you have known this provider for a 
long time. You say that it is unfair that the reimbursement coverage has changed between 2019 to 2020. You 
also say that you were reimbursed $203 for services you received in 2020. The Plan denied your request. The 
Plan says the provider in this case has opted out of Medicare. The Plan also says payment cannot be made to a 
provider that has opted out of Medicare. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
Though the Plan offers a dental benefit in excess of Medicare coverage, dental services received from a 
provider that has opted out of Medicare are not among those covered under this benefit. Therefore, we decided 
that the Plan does not have to reimburse you for the oral exam (D0120), prophylaxis (D1110 x 3), and bitewing 
x-rays (D0274) provided from August 4, 2020, to September 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance provided on December 1, 2021. 
 
You asked the Plan to pay for the dental service. You say that the provider had no idea what the opt out of 
Medicare was all about. You say that the provider is just learning that their patients are being harmed as a 
result. You also say that the provider is requesting an exception be made. The Plan denied your request. The 
Plan says payment cannot be made for services performed by a provider that has opted out of Medicare. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
Though the Plan offers a dental benefit in excess of Medicare coverage, dental services performed by a 
provider that has opted out of Medicare are not among those covered under this benefit. Therefore, we decided 
that the Plan does not have to pay for the periodontal maintenance provided on December 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction, erupted tooth or exposed root (elevation 
and/or forceps removal) (D7140) provided September 28, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the tooth extractions. You say that the network providers did not have 
appointments soon enough to address your pain. The Plan denied your request. The Plan says this service is not 
covered because it was performed OON. 
 
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 tooth 
extractions when the services are rendered by a participating provider. 
 
We looked at the file and Medicare rules. The tooth extraction was performed by an OON provider. Based on 
this information, we decided that the Plan's rules for coverage of the tooth extractions have not been met. Therefore, we decided that the Plan does not have to pay for the extraction, erupted tooth or exposed root 
(elevation and/or forceps removal) (D7140) provided September 28, 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 crown (D2740), periapical x-rays (D0220, D0230), and 
core build up (D2950) provided on August 19, 2021. 
 
You asked the Plan to pay for the periapical x-rays and core build up. You say that you received your first 
crown in May 2021. You say that the provider mistakenly billed for a second crown. You say that the provider 
refiled for the second crown and was paid. You also say that only the second crown should be covered. The 
Plan denied your request. The Plan says the claim was denied 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 1 periapical x-ray is covered per 
calendar year, the frequency limit has been exceeded. The record shows that the Plan paid for periapical x-ray 
that you received on May 27, 2021. Additionally, core build up is not among those covered under this benefit. 
Therefore, we decided that the Plan does not have to pay for the crown (D2740), periapical x-rays (D0220, 
D0230), and core build up (D2950) provided on August 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the destruction of lesion(s) by physical or chemical method 
(D7465) provided on November 1, 2021. 
 
You asked the Plan to pay for the destruction of lesion(s). You say that you would like this service to be 
reconsidered for payment. 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 
destruction of lesion(s) by physical or chemical method (D7465) provided on November 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) 
provided on December 1, 2021. 
 
You asked the Plan to pay for the problem focused limited oral evaluation. You say that the evaluation should 
be a part of the root canal service, which is covered. The Plan denied your request. The Plan says this service is 
not covered under your 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. The only types of exams covered under your dental benefit are routine 
oral exams and comprehensive oral exams. Therefore, we decided that the Plan does not have to pay for the 
problem focused limited oral evaluation (D0140) provided on December 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on 
December 1, 2021. 
 
You asked the Plan to pay for the comprehensive oral evaluation. You say that you are getting over cancer and 
need help with your teeth. The Plan denied your request. The Plan says this service exceeds the frequency 
limitation in 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, comprehensive oral evaluation 
(D0150) is limited to one procedure every three plan years. The record shows that you received a 
comprehensive oral evaluation (D0150) on October 21, 2021 and your comprehensive oral evaluation (D0150) 
benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive 
oral evaluation (D0150) provided on December 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the recement or rebond implant supported crown (D6092) 
provided on October 21, 2021. 
 
You asked the Plan to pay for the dental service. You say that you received the same service for 2 teeth. You 
say that only one of them was covered. You say that the only difference was that one was placed on an implant 
instead of your natural tooth. You also say that reduced coverage would make sense. The Plan denied your 
request. The Plan says the recement or rebond implant supported crown 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 recement or rebond implant 
supported crown is not among those covered under this benefit. Therefore, we decided that the Plan does not 
have to pay for the recement or rebond implant supported crown (D6092) provided on October 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the localized delivery of antimicrobial agents (D4381) and 
two gingival irrigations (D4921 x2) provided on November 16, 2021. 
 
You asked the Plan to pay for the localized delivery of antimicrobial agents and gingival irrigations. You say 
that you would like to appeal these services. The Plan denied your request. The Plan says these services are not 
covered under your 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 
localized delivery of antimicrobial agents (D4381) and two gingival irrigations (D4921 x2) provided on 
November 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the one problem focused limited oral evaluation (D0140), or 
pay more for the resin-based composite (D2392), additional problem focused limited oral evaluation (D0140), 
and first intraoral periapical x-ray (D0220) provided from December 28, 2020, to October 19, 2021. 
 
You asked the Plan to pay for the one problem focused limited oral evaluation, and to pay more for the resin-
based composite, additional problem focused limited oral evaluation, and first intraoral periapical x-ray. You 
say that you would like to appeal these services. The Plan denied your request. The Plan says the problem 
focused limited oral evaluation provided on October 19, 2021 exceeds the frequency limitation under your 
plan. The Plan also says that the claims processed correctly for the resin-based composite, additional problem 
focused limited oral evaluation, and first intraoral periapical x-ray. 
 
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, you are responsible for a 50% 
coinsurance for the resin-based composite (D2392), and you are also responsible for a 20% coinsurance for the 
problem focused limited oral evaluation (D0140), and first intraoral periapical x-ray (D0220). The Plan 
contract also says that emergency oral evaluation problem focused exams are covered once every 12 months. 
The record shows that you received a problem focused limited oral evaluation (D0140) on May 11, 2021 and 
your emergency oral evaluation problem focused exams benefit has been exhausted. Therefore, we decided that 
the Plan does not have to pay for the one problem focused limited oral evaluation (D0140), or pay more for the 
resin-based composite (D2392), additional problem focused limited oral evaluation (D0140), and first intraoral 
periapical x-ray (D0220) provided from December 28, 2020, to October 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown (D2740) provided on December 31, 2021. 
 
You asked the Plan to pay for the dental service. You say that you broke your front tooth. You say that you got 
a quote of $271.50 as a proposed treatment payment. You say that the crown was installed on January 19, 2022. 
You also say that this was an emergency. The Plan denied your request. The Plan says 2 crowns are covered 
per calendar year. The Plan also says that 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 2 crowns are covered per calendar 
year, the frequency limit has been exceeded. The record shows that the Plan paid for 2 crowns that you 
received on July 13, 2021. Therefore, we decided that the Plan does not have to pay for the crown (D2740) 
provided on December 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical extraction (D7210) provided on November 16, 2021. 
 
You asked the Plan to pay for the dental service. You say that this service should be covered. You say that it is 
an extraction of tooth which is covered under your dental plan which has a 50% coinsurance for class 2 basic 
services. The Plan denied your request. The Plan says surgical extraction 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 surgical extraction is not among 
those covered under this benefit. The record shows that only simple extractions are covered. Therefore, we 
decided that the Plan does not have to pay for the surgical extraction (D7210) provided on November 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the immediate lower denture (D5140), and unspecified 
removable prosthodontic service (D5899) provided on November 9, 2021. 
 
You asked the Plan to pay for the dental services. You say that you were advised your out of pocket would be 
$1,396. You say that you paid $396 out of pocket and $1,000 was applied to Care Credit. You say that you are 
being asked for more money. You also say that you are on a low income. The Plan denied your request. The 
Plan says the services 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 immediate lower denture and 
unspecified removable prosthodontic service are not among those covered under this benefit. Therefore, we 
decided that the Plan does not have to pay for the immediate lower denture (D5140), and unspecified 
removable prosthodontic service (D5899) provided on November 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the application of caries arresting medicament (D1354), 
panoramic x-ray (D0330), bitewing x-ray (D0274), periapical x-rays (D0220, 0230 x 3), and comprehensive 
oral evaluation (D0150) provided on November 15, 2021. 
 
You asked the Plan to pay for the dental services. You say that you went to an office that was listed on the 
provider directory given to you by a plan representative. You say that you do not understand being out of 
network. You also say that you feel the services should be covered. The Plan denied your request. The Plan 
says the claim denied 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 and panoramic x-ray, bitewing x-ray, 
and comprehensive oral evaluation are listed as covered, dental services received out of network are not 
covered. Additionally, application of caries arresting medicament and periapical x-rays are not among those 
covered under this benefit regardless of the provider's network status. The record shows that the provider listed 
on the claim is not listed on the provider directory. Therefore, we decided that the Plan does not have to pay for 
the application of caries arresting medicament (D1354), panoramic x-ray (D0330), bitewing x-ray (D0274), 
periapical x-rays (D0220, 0230 x 3), and comprehensive oral evaluation (D0150) provided on November 15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
August 8, 2021, to August 12, 2021. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. The Plan denied your request. The 
Plan says you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $280 
copayment per day for days 1-6 of an inpatient hospital stay. The Plan contract also says there is no charge 
after day 6. There is also no charge for the day of discharge. You have been asked to pay a total of $1,120, which is a $280 copayment for a four-day inpatient hospital stay ($280 copayment x 4 days = $1,120). An inpatient hospital stay falls within the Inpatient Hospital Care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from August 
8, 2021, to August 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for the adjunctive prediagnosic test 
(D0431) and scaling and root planing (D4341 x 3) provided on December 8, 2021. 
 
You asked the Plan to pay an additional amount for the dental services. You say that you believe that this claim 
was processed under your 2020 dental plan. You say that your current plan covers 100% for covered services 
up to $2,000. You say that this should be reprocessed under the correct dental coverage. You also say that a 
plan representative advised this claim was processed incorrectly. The Plan denied your request. The Plan says 
scaling and root planing is covered once per quadrant every 2 years. The Plan says that there is a 50% 
coinsurance that applies to this service. The Plan says that adjunctive prediagnostic test is not listed as a 
covered service. The Plan also says that although you were given incorrect information regarding the services 
you received, it was given after the services were performed.  
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 scaling and root planing is listed as 
covered, there is a 50% coinsurance that applies. This is a contractual obligation you agreed to when you 
enrolled in the Plan's dental coverage. Additionally, the adjunctive prediagnostic test is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay an additional amount for 
the adjunctive prediagnosic test (D0431) and scaling and root planing (D4341 x 3) provided on December 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), 
bitewing x-rays (D0274), and panoramic x-ray (D0330) provided on December 3, 2021. 
 
You asked the Plan to pay for the problem focused limited oral evaluation, bitewing x-rays, and panoramic x-
ray. You say that you feel these services should be covered because it was an emergency. The Plan denied your 
request. The Plan says you have met the $2,000 maximum for the 2021 plan year. 
 
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 a $0 copay up to the 
$2,000 allowance for all covered dental services. The contract says that you pay 100% of charges beyond the 
$2,000 allowance. The record shows that you met the annual maximum benefit on December 6, 2021 and your 
annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the 
problem focused limited oral evaluation (D0140), bitewing x-rays (D0274), and panoramic x-ray (D0330) 
provided on December 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for the fillings (D2391, D2392, D2393), 
and surgical extraction (D7210) provided on June 2, 2021. 
 
You asked the Plan to pay an additional amount for the dental services. You say that your cost share was more 
than the amount the insurance covered. You also say that you believe the amount you paid should have been in 
your favor. The Plan denied your request. The Plan says the claim processed 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 and the services are listed as covered, 
there are cost shares that apply. The record shows that you pay 50% coinsurance for basic restorative services, 
including fillings, and a 70% coinsurance for surgical extractions.  
 
Procedure Code Allowed Amount Coinsurance Plan Paid Your Responsibility 
D2391 $88.75 50% $44.28 $44.29 
D2392 $115.23 50% $57.61 $57.62 
D2393 $143.55 50% $71.77 $71.78 
D7210 $142.31 70% $42.69 $99.62 
TOTAL: $489.66  $216.35 $273.31 
 
Therefore, we decided that the Plan does not have to pay an additional amount for the fillings (D2391, D2392, 
D2393), and surgical extraction (D7210) provided on June 2, 2021.