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

 
We decided that the Plan does not have to provide additional payment for the crowns - porcelain/ceramic 
(D2740) provided January 21, 2022. 
 
You asked the Plan to provide additional payment for the crowns. You say that you paid for extra insurance 
and don't understand how the Plan can now deny this service. The Plan denied your request. The Plan says you 
have exhausted 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 covers the crowns up 
to a $1,500 annual maximum. 
 
We looked at the file and Medicare rules. The Plan provided documentation showing that at the time of the 
service you had $851 remaining in your annual maximum. This amount was applied to your claims. Therefore, 
we decided that the Plan does not have to provide additional payment for the crowns - porcelain/ceramic 
(D2740) provided January 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral exam (code D0150) you received on 
November 29, 2021. 
 
You asked the Plan to pay for the comprehensive oral exam. You say that this was a routine dental cleaning 
which is covered twice a year. The Plan denied your request. The Plan says you already exhausted your benefit 
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 Plans coverage rules apply in this case. Your contract says that 
comprehensive oral exams are covered once every 36 months.  You last received a covered comprehensive oral 
exam on May 18, 2021, so you were not eligible for another one on the date of service in question in this 
appeal. 
 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) you received on November 29, 2021.  
 
Your complaint about this service only being for a routine cleaning 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 vertical bitewing x-rays (code D2777) and the 
comprehensive periodontal evaluation (code D0180) you received on August 30, 2021. 
 
You asked the Plan to pay for the vertical bitewing x-rays (code D2777) and the comprehensive periodontal 
evaluation (code D0180). You did not provide a specific argument with your appeal request. The Plan denied 
your request. The Plan says these are not covered services 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 those services and codes specifically listed in your Deluxe Mandatory Dental 
Benefits chart. The vertical bitewing x-rays (code D2777) and the comprehensive periodontal evaluation (code 
D0180) are not listed as covered services in this chart. 
 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 
vertical bitewing x-rays (code D2777) and the comprehensive periodontal evaluation (code D0180) you 
received on August 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the application of desensitizing medicaments (code D9910), 
and the fillings (codes D2391 and D2332) you received on January 28, 2022. 
 
You asked the Plan to pay for the application of desensitizing medicaments and the fillings. You say that you 
would like the Plan to reconsider its denial. The Plan denied your request. The Plan says the application of 
desensitizing medicaments (code D9910) is not a covered benefit.  The Plan also says that you are not eligible 
for coverage of additional fillings. 
 
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 services: exams, x-rays, cleanings, fillings, extractions, crowns, 
dentures, and anesthesia.  In relation to fillings, you are limited to two procedures per calendar year.  The application of desensitizing medicaments (code D9910) is not listed as a covered service.  On this date of 
service, you had six fillings.  The Plan covered two of these fillings because your Evidence of Coverage limits 
coverage of fillings to two per calendar year.  As such, you have exhausted this benefit for 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 
application of desensitizing medicaments (code D9910), and the fillings (codes D2391 and D2332) you 
received on January 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services you received from January 25, 2021, to 
August 17, 2021. 
 
You asked the Plan to pay for the dental services. You say that the dentist did not inform you that he no longer 
accepted Medicare patients. The Plan denied your request. The Plan says this provider has opted-out of 
Medicare and therefore these services are not covered. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for dental 
services you received from January 25, 2021, to August 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the crown buildup you received on October 25, 2021, 
and the crown you received from an out-of-network dentist on November 10, 2021. 
 
You asked the Plan to pay more for the crown buildup and crown. You say that you do not understand why the 
Plan didn't pay more for these services. The Plan denied your request. The Plan says has paid for these services 
in accordance with your contract. 
 
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 contract says that 
you have a $100 calendar year deductible for dental services.  After this deductible is met, the Plan will pay for 
major dental services (including crowns) with 50% coinsurance of the covered plan allowance. You'll save more when you receive care from an in-network dentist. You can get care from an out-of-network dentist, but 
you may pay more. 
 
In this case, the total billed amount was $1945.00.  However, the Plan-allowed amount for these services is 
$519.50.  Had you gone to a Plan dentist, this would have been the maximum amount they could charge you 
for these services.  Since you went to an out-of-network dentist, they can charge more than the Plan-allowed 
amount, and you are responsible for the difference.  The $100 deductible was applied to this allowance, leaving 
a total of $419.50.  According to your contract, you have 50% coinsurance based on the Plan-allowed amount, 
meaning that the Plan will pay the other 50% of the Plan-allowed amount (which is $209.75).  This is the 
amount paid for these services. 
 
Therefore, we decided that the Plan does not have to pay more for the crown buildup you received on October 
25, 2021, and the crown you received from an out-of-network dentist on November 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete series dental x-rays (code D0330) you received 
on October 12, 2021. 
 
You asked the Plan to pay for the complete series dental x-rays. You say that the first set of x-rays you received 
were not any good, so this set of x-rays should be covered. The Plan denied your request. The Plan says you 
were not eligible for the complete series dental x-rays on the date of service in question. 
 
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 a 
complete series of dental x-rays once every five years.  Records show that you already received a covered 
complete series of dental x-rays on September 19, 2019, so you will not be eligible for this service again until 
after September 19, 2024. This rule applies even if you are dissatisfied with the initial set of x-rays. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
complete series dental x-rays (code D0330) you received on October 12, 2021.  
 
Your complaint about your first set of x-rays not being any good 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 dental services provided on October 5, 2021 to October 14, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the dental services. You say that it was difficult to find a network provider due to 
the COVID-19 pandemic, so this should be covered. The Plan denied your request. The Plan says unauthorized, 
non-plan care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service 
at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we 
decided that the Plan does not have to pay for dental services provided on October 5, 2021 to October 14, 2021, 
by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the cleaning, comprehensive oral 
evaluation, and intraoral complete x-rays rendered on January 5, 2022. 
 
You asked the Plan to waive the copayments for these services. You say that the out-of-network dentist was 
recommended as a specialist at implant surgery. 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 Plan's coverage rules apply in this case. The Plan covers services from 
an out-of-network provider only up to a certain amount, and you may be billed for any amount greater than 
what the Plan pays.  We looked at the file and Medicare rules. The file shows that you received supplemental dental services from an out-of-network provider on January 5, 2022. The Plan paid 100 percent of the allowable amount for these 
services. Further payment is not covered by Medicare or your supplemental dental benefit. Therefore, we 
decided that the Plan does not have to waive the copayments for the cleaning, comprehensive oral evaluation, 
and intraoral complete x-rays rendered on January 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for resin-based composite, three surfaces, anterior (D2332) 
resin-based composite, four or more surfaces (D2335) provided January 20, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told by the dentist that this procedure 
would be covered in full. The dental office is now billing you and additional $112 that was not covered by the 
Plan. The Plan denied your request. The Plan says the claim was processed and the correct cost share was 
applied per the Evidence of Coverage. 
 
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 there is a $500 annual 
maximum benefit for Dental services.  
 
You have been asked to pay $112.00. The provider billed $532 for the services and the Plan paid $500. The $500 annual maximum benefit has been met for this benefit year. The services fall within the 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 pay for resin-based composite, three surfaces, anterior 
(D2332) resin-based composite, four or more surfaces (D2335) provided January 20, 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) provided February 1, 2022. 
 
You asked the Plan to pay for the comprehensive oral exam. You say that this exam was necessary to evaluate 
whether you needed a root canal. The Plan denied your request. The Plan says you have exceeded the 
frequency 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 Plans coverage rules apply in this case. The Plan covers the 
comprehensive oral exam once every three plan years.  
 
We looked at the file and Medicare rules. The Plan provided documentation showing that a comprehensive 
exam was previously covered on January 5, 2022. Based on this information, we decided that the Plan's frequency limit for coverage of the comprehensive oral exam has been exceeded. Therefore, we decided that 
the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150) 
provided February 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental implants you received on October 15, 2021. 
 
You asked the Plan to pay for the dental implants. You say that these implants were needed due to your kidney 
disease.  Loose teeth put you at high risk of infection, so this should be covered. The Plan denied your request. 
The Plan says dental implants are not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers only for those 
dental services listed in your Dental Benefits Chart.  Dental implants are not listed in this chart, so they would 
not be covered for any reason. 
 
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 implants you received on October 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for ophthalmology services provided on December 2, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the ophthalmology services. You say that this patient resides in a nursing facility and required ophthalmology services.  The facility should have obtained authorization. The Plan denied your request. The Plan says unauthorized, non-plan care is not covered.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for ophthalmology services provided on December 2, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inhalation of nitrous oxide/analgesia (D9230). 
 
You asked the Plan to pre-approve inhalation of nitrous oxide/analgesia. You say that you would like this 
service to be approved for coverage. The Plan denied your request. The Plan says this service 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. 
 
 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 
inhalation of nitrous oxide/analgesia (D9230).
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the sales tax associated with COVID-19 testing 
rendered on February 5, 2022. 
 
You asked the Plan to reimburse you 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 Medicare does not make any additional payment for 
sales taxes and do not make adjustments in fees to reflect local changes in tax rates. 
 
We looked at the file and Medicare rules. You are requesting reimbursement for sales tax. This is not covered 
by Medicare. Therefore, we decided that the Plan does not have to reimburse you for the sales tax associated 
with COVID-19 testing rendered on February 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive dental exam (code D0150) and the 
complete services of x-rays (code D0210) you received on February 24, 2022. 
 
You asked the Plan to pay for the comprehensive dental exam and the complete series of x-rays. You say that 
you were not told that you needed to check your coverage before getting these services. The Plan denied your 
request. The Plan says you were not eligible for these services because you had exhausted the benefit for them. 
 
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 contract says that 
comprehensive dental exams are only covered once every three calendar years and full series x-rays are only 
covered once every five years.  Records show that you received coverage for a comprehensive oral exam and 
complete series of x-rays on December 1, 2020, so you were not eligible for these services on the date of 
service in question.  
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 dental exam (code D0150) and the complete services of x-rays (code D0210) you received on 
February 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral exam (code D0150) you received on 
November 29, 2021. 
 
You asked the Plan to pay for the comprehensive oral exam. You say that you believe this was a routine 
cleaning, which is covered twice a year The Plan denied your request. The Plan says this service is only 
covered once every 36 months, and you were not eligible for this service on the date of service in question. 
 
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. Records show that you already 
received a covered comprehensive oral exam on May 18, 2021.  You are not eligible for another 
comprehensive oral exam until May 18, 2024.  This service was not a routine cleaning, it was a comprehensive 
dental exam. 
 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) you received on November 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided by an out-of-
network provider on November 23, 2021. 
 
You asked the Plan to pay for a limited oral evaluation. You say that this was more of an emergency. The Plan 
denied your request. The Plan says the benefit limit for D0140 as already been met and exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a limited oral 
evaluation when the services are medically necessary and reasonable.  
 
We looked at the file and Medicare rules. Evidence was provided to show that D0140 was previously provided 
on May 22, 2021. Based on this information, we decided that the Plan's rules for coverage of a limited oral 
evaluation have not been met. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided by an out-of-network provider on November 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (82728, 83540, and 83550) provided 
on December 8, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the laboratory services (82728, 83540, and 83550) provided on December 8, 2021.