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

 
We decided that the Plan does not have to pay for unspecified periodontal procedure (D9125, D4999) provided 
on June 30, 2022. 
 
You asked the Plan to pay for the unspecified periodontal procedure. You say that the services should be 
covered as you disagree with the denial. The Plan denied your request. The Plan says the services denied 
correctly as they do not fall within 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 
unspecified periodontal procedure (D9125, D4999) provided on June 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

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

 
We decided that the Plan does not have to pre-approve the scaling and root planning (D4342), a partial upper 
denture (D5225), and a partial lower denture (D5226), 
 
You asked the Plan to pre-approve the dental services. You say that your old dentures broke, and you need new 
ones. 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 scaling and root planning was exhausted on the date of service of March 24, 2021, 
the record also shows your benefit for the partial dentures was exhausted on the date of service of January 24, 
2022. Therefore, we decided that the Plan does not have to pre-approve the scaling and root planning (D4342), 
a partial upper denture (D5225), and a partial lower denture (D5226),
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prefabricated abutment (D6056) and an endosteal 
implant (D6010) provided by a participating provider. 
 
You asked the Plan to pre-approve a prefabricated abutment and an endosteal implant. You say that you were 
told that these services were covered. The Plan denied your request. The Plan says the rendered dental services 
are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
prefabricated abutment (D6056) and an endosteal implant (D6010) provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown on tooth #6 (D2740) provided on February 2, 2022, 
and an occlusal guard (D9946) provided on February 15, 2022. 
 
You asked the Plan to pay for a crown and guard. You say that you disagree with denial of dental services. The 
Plan denied your request. The Plan says a crown (D2740) and occlusal guard (D9946) 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 crown 
on tooth #6 (D2740) provided on February 2, 2022, and an occlusal guard (D9946) provided on February 15, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical placement of mini implant tooth #'s 21, 23, 
26, and 28 (D6013). 
 
You asked the Plan to pre-approve the surgical placement of mini implant tooth #'s 21, 23, 26, and 28 (D6013). 
The Plan denied your request. The Plan says this service is not covered under the benefit package. 
 
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 mini implant tooth #'s 21, 23, 26, and 28 (D6013).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive oral evaluation - new or established patient 
(D0150) and intraoral - complete series of radiographic image (D0210) provided on June 2, 2022. 
 
You asked the Plan to pay for dental services. You say that you cannot afford to pay for the services. The Plan 
denied your request. The Plan says the service is covered but limitations apply. 
 
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. This benefit includes 
comprehensive oral evaluation - new or established patient (D0150)  one procedure code every three calendar 
years and intraoral - complete series of radiographic image (D0210)  one procedure code every five calendar 
years. 
 
  We looked at the file, the Plans rules, and Medicares rules. You previously received covered comprehensive 
oral evaluation - new or established patient (D0150) on March 16, 2020, and intraoral - complete series of 
radiographic image (D0210) on May 29, 2019. Therefore, these benefits were exhausted. Therefore, we 
decided that the Plan does not have to pay for comprehensive oral evaluation - new or established patient 
(D0150) and intraoral - complete series of radiographic image (D0210) provided on June 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for palliative treatment (D9110) provided on July 22, 2022. 
 
You asked the Plan to pay for palliative treatment. You say that it is unfair to have to pay so much out-of-
pocket. The Plan denied your request. The Plan says palliative treatment (D9110) is 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 palliative 
treatment (D9110) provided on July 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a core buildup services and dental pontic (D2950, D6245) 
provided on July 11, 2022 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your $2,000 dental benefit maximum allowance 
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 July 11, 2022. Therefore, 
we decided that the Plan does not have to pay for a core buildup services and dental pontic (D2950, D6245) 
provided on July 11, 2022
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on July 25, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service July 25, 2022. Therefore, 
we decided that the Plan does not have to pay for the dental services on July 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a retainer crown (D6750) and a pontic (D6240). 
 
You asked the Plan to pre-approve a retainer crown and a pontic. You say that you need these services. 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 
retainer crown (D6750) and a pontic (D6240).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services. 
 
You asked the Plan to pre-approve the dental services. You say that due to your age, you do not drive out of 
your town, there are no in-network providers near you. The Plan denied your request. The Plan says dental 
services from an out-of-network provider are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
You are requesting 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 pre-approve dental 
services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for adjunctive pre-diagnostic test that aids in detection of 
mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy 
procedures (D0431) provided on June 6, 2022.  
 
You asked the Plan to pay for dental services. You say that you called the Plan, and they recommended this 
provider, they did not tell you they were out-of-network. 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. Adjunctive pre-diagnostic test 
that aids in detection of mucosal abnormalities including premalignant and malignant lesions, not to include 
cytology or biopsy procedures (D0431) is not covered under the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested adjunctive pre-diagnostic 
test that aids in detection of mucosal abnormalities including premalignant and malignant lesions, not to 
include cytology or biopsy procedures (D0431) is not among those covered under this benefit. Therefore, we 
decided that the Plan does not have to pay for adjunctive pre-diagnostic test that aids in detection of mucosal 
abnormalities including premalignant and malignant lesions, not to include cytology or biopsy procedures 
(D0431) provided on June 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary and mandibular denture (D5110 
and D5120) provided by a participating provider. 
 
You asked the Plan to pre-approve the dental services. You say that you were in a hit and run bicycle accident 
and your dentures were broken. 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 May 15, 2019. Therefore, 
we decided that the Plan does not have to pre-approve a complete maxillary and mandibular denture (D5110 
and D5120) provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom fabricated abutment (D6057) and an abutment 
supported crown (D6061) provided by an out-of-network provider. 
 
You asked the Plan to pre-approve a custom fabricated abutment and an abutment supported crown. You say 
that you need this dental work. The Plan denied your request. The Plan says the requested 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 pre-approve a 
custom fabricated abutment (D6057) and an abutment supported crown (D6061) provided by an out-of-network 
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial upper denture (D5213). 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee needs a new partial denture. 
The Plan denied your request. The Plan says your benefit for the requested item or service has already been 
exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the enrollees benefit for the requested item or service was exhausted on the date of service of July 14, 
2021. Therefore, we decided that the Plan does not have to pre-approve a partial upper denture (D5213).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary and mandibular denture (D5110 
and D5120) provided by a participating provider. 
 
You asked the Plan to pre-approve the dental services. You say that you never had dentures provided on 
August 2, 2019. 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 July 18, 2019. Therefore, 
we decided that the Plan does not have to pre-approve a complete maxillary and mandibular denture (D5110 
and D5120) provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an abial veneer (resin laminate) - direct tooth # 25 (D2960) 
provided on June 27, 2022. 
 
You asked the Plan to pay for the abial veneer (resin laminate) - direct tooth # 25 (D2960). You say that the 
procedure was an essential medical service and you went the cheapest method to have the tooth repaired. The 
Plan denied your request. The Plan says this service is not covered under the benefit package. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an abial 
veneer (resin laminate) - direct tooth # 25 (D2960) provided on June 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the adjunctive pre-diagnostic test that aids in detection of 
mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy 
procedures (D0431) provided on August 11, 2022. 
 
You asked the Plan to pay for the adjunctive pre-diagnostic test. You say that the dentist should know what 
procedures are 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 the adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities including premalignant and 
malignant lesions, not to include cytology or biopsy procedures (D0431) provided on August 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve osseous, osteoperiosteal, or cartilage graft of the 
mandible or maxilla (D7950), and sinus augmentation with bone or bone substitutes via a lateral open approach 
(D7951). 
 You asked the Plan to pre-approve dental services. You say that you need the requested services because you 
cannot eat. 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. Osseous, osteoperiosteal, or 
cartilage graft of the mandible or maxilla (D7950), and sinus augmentation with bone or bone substitutes via a 
lateral open approach (D7951) are not covered under the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested osseous, osteoperiosteal, 
or cartilage graft of the mandible or maxilla (D7950), and sinus augmentation with bone or bone substitutes via 
a lateral open approach (D7951) are not among those covered under this benefit. Therefore, we decided that the 
Plan does not have to pre-approve osseous, osteoperiosteal, or cartilage graft of the mandible or maxilla 
(D7950), and sinus augmentation with bone or bone substitutes via a lateral open approach (D7951).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement graft for ridge preservation - per site 
tooth #21 (D7953), and surgical placement of implant body: endosteal implant tooth #'s 19 and 21 (D6010). 
 
You asked the Plan to pre-approve the bone replacement graft for ridge preservation - per site tooth #21 
(D7953), and surgical placement of implant body: endosteal implant tooth #'s 19 and 21 (D6010). The Plan 
denied your request. The Plan says these services are not covered under the benefit package. 
 
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 
bone replacement graft for ridge preservation - per site tooth #21 (D7953), and surgical placement of implant 
body: endosteal implant tooth #'s 19 and 21 (D6010).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on July 
11, 2022 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service July 10, 2021. Therefore, 
we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on July 
11, 2022
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical placement of implant body (D6010) for 
tooth #18, #20, #24, and #31. 
 
You asked the Plan to pre-approve the dental services. You say that the dental implants are medically necessary 
for the enrollee. 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 the date of service of July 20, 2022. 
Therefore, we decided that the Plan does not have to pre-approve the surgical placement of implant body 
(D6010) for tooth #18, #20, #24, and #31.