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

 
We decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture and 
interpretation with limited field of view  less than one whole jaw (D0364) provided February 7, 2022. 
 
You asked the Plan to pay for the cone beam CT scan. You say that this service was necessary to evaluate your 
dental problem. 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 cone 
beam computed tomography (CT) capture and interpretation with limited field of view  less than one whole 
jaw (D0364) provided February 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay the remaining balance of  reline complete maxillary denture 
(code D5750) provided on January 19, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay the remaining balance of the denture reline. You say that you were told this service 
would be 100% covered. The Plan denied your request. The Plan says the Plan paid 100% of the allowed 
amount for the service ($244). The Plan also says that any amount above the allowed amount may be the 
enrollees responsibility. 
 
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 Plan does not have to pay more 
than the allowed amount for covered items and services. Therefore, we decided that the Plan does not have to 
pay the remaining balance of  reline complete maxillary denture (code D5750) provided on January 19, 2022, 
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 dental services rendered on January 25, 2022. 
 
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 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. The Plan covers services from 
an out-of-network provider subject to allowed amount maximums. 
 
We looked at the file and the Plans rules. The file shows that you received supplemental dental services from 
an out-of-network provider. The Plan processed the claim for these services and paid up to the maximum 
allowed amount. Further payment is not covered by your medical benefit or your supplemental dental benefit. 
Therefore, we decided that the Plan does not have to pay for the dental services rendered on January 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cone beam imaging (code D0365) provided on December 13, 2021. 
 
You asked the Plan to pay for the imaging. You say that you should not have to pay the entire claim. The Plan 
denied your request. The Plan says that cone beam imaging is not covered by the Plan's 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 cone 
beam imaging (code D0365) provided on December 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital discharge day management services (99239) 
provided on October 13, 2021. 
 
You asked the Plan to pay for the hospital discharge day management services. You say that you would like 
this claim reprocessed based on the medical records. The Plan denied your request. The Plan says the 
documentation does not support the billed CPT code 99239. 
 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99239 is hospital discharge day management; more than 
30 minutes. 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, the documentation does not 
support that more than 30 minutes were spent on hospital discharge day management services. Based on this 
information, we decided that Medicare rules for coverage of the hospital discharge day management services 
have not been met. Therefore, we decided that the Plan does not have to pay for the hospital discharge day 
management services (99239) provided on October 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the occlusal guard you received on January 17, 2022. 
 
You asked the Plan to pay for the occlusal guard. You say that you had a night guard in the past and it worked 
for you, so you need the Plan to pay for this. The Plan denied your request. The Plan says this item 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. The only dental services 
covered by your Plan are as follows: exams, x-rays, cleanings, fluoride, nutritional counseling, and application 
of medication to stop cavity formation. 
 
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 
occlusal guard you received on January 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral exam (code D0140) you received on 
February 16, 2022. 
 
You asked the Plan to pay for the limited oral exam. You say that you called the Plan prior to your appointment 
to confirm what was covered. The Plan denied your request. The Plan says this service is not covered under 
your dental benefits. The Plan acknowledges that you called them to verify benefits, but on that call you 
specifically asked only about oral surgeons and benefits for extractions and implants. The Plan offered to send 
you a full benefits listing, but you refused. 
 
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. Your dental benefit only 
covers those dental services explicitly listed in your dental benefits chart.  Limited oral exams are not listed as 
a covered benefit. 
 
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 
limited oral exam (code D0140) you received on February 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral exam (code D0140) you received on 
February 17, 2022. 
 
You asked the Plan to pay for the limited oral exam. You say that you had to have a second evaluation with the 
dentist who would be pulling out your teeth. The Plan denied your request. The Plan says you had already 
exhausted this 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. The Plan's rules explicitly 
states that limited oral exams (code D0140) are only covered once per plan year. This limitation applies 
regardless of the reason for the exam. Records show that you had already received a covered limited oral exam 
on January 20, 2022. 
 
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 limited oral exam (code D0140) you received 
on February 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral exam (code D0140) you had on February 16, 2022. 
 
You asked the Plan to pay for the limited oral exam. You say that you went to the dentist to have a denture 
evaluation.  You said that under your plan, dentures are covered so this visit should be covered. The Plan 
denied your request. The Plan says you had already exhausted the limit for this 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. The Plan's dental coverage 
only covers once limited oral exam (code D0140) every plan year.  You had already received a covered limited 
oral exam on February 9, 2022, so you were not eligible for another one when you had the exam on February 
16, 2022. 
 
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 
limited oral exam (code D0140) you had on February 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services you received from an out-of-network dentist 
on February 21, 2022. 
 
You asked the Plan to pay for the out-of-network dental services. You say that you would like this claim 
processed. The Plan denied your request. The Plan says dental services you receive from an out-of-network 
dentist 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 Plans coverage rules apply in this case. Your Plan only covers dental 
services when received from a network dentist.  You did not use a network dentist. 
 
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 dental 
services you received from an out-of-network dentist on February 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for dental services you received on November 8, 2021. 
 
You asked the Plan to pay more for the dental services. You say that you do not believe that you have been 
paid the full allowed amount. The Plan denied your request. The Plan says you have already met your annual 
allowance for dental coverage. 
 
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. Your dental benefit only 
covers dental services up to $1,000 per year.  The Plan had already paid this amount for dental care in 2021, so 
no additional payment is due. 
 
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 more for 
dental services you received on November 8, 2021.  
 
Your complaint about the Plan paying the dental provider for services on July 22, 2021, when you claim you 
had already paid the provider in cash 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 tooth extraction rendered on November 11, 2021. 
 
You asked the Plan to pay for these services. You say that a Plan representative told you that you could go to 
this provider. The Plan denied your request. The Plan says the services were rendered by 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. The Plan contract says that 
enrollees must pay 100% for supplemental dental benefits from an out-of-network provider. 
 
We looked at the file and the Plan's rules. The file shows that you received a tooth extraction from an out-of-
network dentist. The file shows that you were told on September 28, 2021 during your enrollment call that you 
must see an in-network dentist. Based on this information, we decided that the Plan's rules for coverage of 
these services have not been met. Therefore, we decided that the Plan does not have to pay for the tooth 
extraction rendered o November 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prefabricated post and core (code D2954) and the 
endodontic therapy (code D3310) you received from an out-of-network dentist on January 18, 2022. 
 
You asked the Plan to pay for the prefabricated post and core and the endodontic therapy. You say that this was 
a dental emergency so this should be covered. The Plan denied your request. The Plan says these services are 
not covered under 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. The Plan's dental benefit only 
covers certain preventive dental services when received from a network dentist.  The services you received 
were neither covered preventive services nor were they provided by a network dentist. 
 
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 
prefabricated post and core (code D2954) and the endodontic therapy (code D3310) you received from an out-
of-network dentist on January 18, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the cost share for a ceftriaxone sodium injection (code J0696) provided 
on August 19, 2021. 
 
You asked the Plan to waive the cost share for an injection. You say that you saw a participating provider and 
there should be no charges. The Plan denied your request. The Plan says that you have been charged the correct 
cost sharing amount. 
 
The Plan says you must pay 20% coinsurance for an injection. According to Medicare, code J0696 is 
considered a packaged code and is not separately payable. Therefore, we decided that the Plan has to waive the 
cost share for a ceftriaxone sodium injection (code J0696) provided on August 19, 2021.  
 
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 waive the coinsurance for extractions (D7140 and D7210) provided 
by an out-of-network provider on December 30, 2021. 
 
You asked the Plan to waive the coinsurance for extractions. You say that you do not agree with these charges. 
The Plan denied your request. The Plan says the correct coinsurance has been applied. 
 
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 50% 
coinsurance for dental services/major dental services.  
 
 You have been asked to pay a 50% coinsurance of the allowed amount for extractions. The total allowed 
amount is $149.50. The total amount you are being asked to pay is $74.75 ($149.50 x 50% = $74.75). 
Extractions fall within the dental services/major dental services 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 coinsurance for extractions (D7140 and D7210) provided by an out-of-network on December 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services you received on February 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were never told that these services would 
not be covered and you feel as though the dentist took advantage of you. The Plan denied your request. The 
Plan says dental care with an out-of-network dentist is not 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. The Plan's dental benefit 
includes coverage of dental services only when you use your assigned network dentist except for emergency 
and written authorizations for specialty care approved in advance. You did not use a network dentist for these 
services and you did not have prior authorization. 
 
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 dental 
services you received on February 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral exam (code D0150) and the complete 
series dental x-rays (code D0210) you received on February 3, 2022. 
 
You asked the Plan to pay for the comprehensive oral exam and the complete series dental x-rays. You say that 
you are questioning the Plan's denial. The Plan denied your request. The Plan says you were not eligible for 
these 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. The Plan's dental benefit 
explicitly states that comprehensive oral exams and complete series x-rays are only covered once every three 
years.  Records show that you already received a covered comprehensive oral exam and complete series x-rays 
on December 30, 2020, so you are not eligible for these services again until after December 30, 2023.  
 
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 
comprehensive oral exam (code D0150) and the complete series dental x-rays (code D0210) you received on 
February 3, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate services (20939). 
 
You asked the Plan to pre-approve bone marrow aspirate services. You say that this is medically reasonable 
and necessary. The Plan denied your request. The Plan says the medical necessity for the requested services 
have not been established after clinical review and per the peer-reviewed literature. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 pre-approve bone marrow aspirate services. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the requested bone marrow aspirate remains experimental for use as bone 
graft in spine surgery. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bone marrow aspirate services have not been met. Therefore, we decided that 
the Plan does not have to pre-approve bone marrow aspirate services (20939).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral exam (code D0140), the periapical x-rays 
(D0220 and D0230), and application of desensitizing medicament (D9910) you received on January 31, 2022. 
 
You asked the Plan to pay for the limited oral exam, the periapical x-rays ), and application of desensitizing 
medicament. You say that you believe you have submitted all of the needed information to get reimbursed. The 
Plan denied your request. The Plan says these services are not covered under your dental 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. The Plan's dental benefit 
includes coverage only for the following dental services: periodic oral exams, periodontal exams, 
comprehensive oral exams, bitewing x-rays. cleanings, fillings, and anesthesia. The benefit does not cover the 
specific dental services you received.  
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 
limited oral exam (code D0140), the periapical x-rays (D0220 and D0230), and application of desensitizing 
medicament (D9910) you received on January 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services (D9995) provided on February 28, 2022. 
 
You asked the Plan to pay for dental code D9995. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says dental code D9995 is not covered under the 
Plan's 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, dental code D9995 is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental services 
(D9995) provided on February 28, 2022.