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

 
We decided that the Plan has to pre-approve scaling and root planing (D4341) for all 4 quadrants. 
 
You asked the Plan to pre-approve scaling and root planing. You say that you have been to three different 
dental providers. You say that they all have advised you to do root planing. You also say that you have been 
diagnosed with bone loss. The Plan denied your request. The Plan says that there is not significant enough bone 
loss to warrant scaling and root planing. 
 
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 scaling and 
root planing when the services are medically necessary and reasonable. 
 
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 scaling and root planing. Our reviewer 
says that the scaling and root planing for all 4 quadrants is medically necessary. Our physician reviewer found 
the provided documentation indicates there are significant periodontal pockets in all quadrants with areas of 
bone loss. Therefore, the reviewer found that the requested services are medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of scaling and root planing have been met. Therefore, we decided that the Plan has 
to pre-approve scaling and root planing (D4341) for all 4 quadrants.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an evaluation office visit with a specialist, a follow up 
office visit, the repair of intermediate wounds of the face, the excision of a malignant lesion including the 
margins and face, the excision of a malignant lesion including margins of the scalp, neck, hands, feet, and 
genitalia, the destruction of first premalignant lesion, the destruction of premalignant lesions second through 14 
lesions, a tangential biopsy of the skin for a single lesion, a tangential biopsy of the skin for each separate or 
additional lesion, and the repair of intermediate wounds of the neck, hands, feet and or external genitalia to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an evaluation office visit with a specialist, a follow up office visit, the repair 
of intermediate wounds of the face, the excision of a malignant lesion including the margins and face, the 
excision of a malignant lesion including margins of the scalp, neck, hands, feet, and genitalia, the destruction of 
first premalignant lesion, the destruction of premalignant lesions second through 14 lesions, a tangential biopsy 
of the skin for a single lesion, a tangential biopsy of the skin for each separate or additional lesion, and the 
repair of intermediate wounds of the neck, hands, feet and or external genitalia. You say that the member has 
his next appointment with the requested provider on November 22, 2022. The Plan denied your request. The 
Plan says these services are available in-network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an evaluation office visit with a specialist, a follow up office visit, the repair of intermediate wounds of the 
face, the excision of a malignant lesion including the margins and face, the excision of a malignant lesion 
including margins of the scalp, neck, hands, feet, and genitalia, the destruction of first premalignant lesion, the 
destruction of premalignant lesions second through 14 lesions, a tangential biopsy of the skin for a single 
lesion, a tangential biopsy of the skin for each separate or additional lesion, and the repair of intermediate 
wounds of the neck, hands, feet and or external genitalia to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of an implant body: endosteal 
implants (D6010 x 3), implant supported porcelain/ceramic crowns (D6065 x 3), and prefabricated abutments
includes modification and placement (D6056 x 3). 
 
You asked the Plan to pre-approve these dental items. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says these items are not a covered benefit under your 
contractual policy. 
 
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 are not among 
those covered under this benefit.  Therefore, we decided that the Plan does not have to pre-approve surgical placement of an implant body: 
endosteal implants (D6010 x 3), implant supported porcelain/ceramic crowns (D6065 x 3), and prefabricated 
abutmentsincludes modification and placement (D6056 x 3).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retainer crowns on tooth #13 and 15 (D6720) and a 
pontic on tooth #14 (D6245). 
 
You asked the Plan to pre-approve the dental services. You say that you disagree with the denial of dental 
services. The Plan denied your request. The Plan says your benefit for the requested items or services 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 items or services was exhausted on date of service April 29, 2022. 
Therefore, we decided that the Plan does not have to pre-approve retainer crowns on tooth #13 and 15 (D6720) 
and a pontic on tooth #14 (D6245).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system. 
 
You asked the Plan to pre-approve the requested item. The Plan denied your request. The Plan says the power 
seat elevation is not medical in nature. 
 The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Therefore, we 
decided that the Plan does not have to pre-approve a power seat elevation system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on March 4, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are being billed the noncovered amount and 
coinsurance for dental services received. You say that you were not told about the benefit period maximum 
allowance. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service March 4, 2022. 
Therefore, we decided that the Plan has paid the full $1,000 dental benefit for services provided for Plan year 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve guided tissue regenerate, per site  teeth #2, 3 and bone 
replacement graft  teeth #2, 3. 
 
You asked the Plan to pre-approve guided tissue regenerate, per site  teeth #2, 3 and bone replacement graft  
teeth #2, 3. The Plan denied your request. The Plan says guided tissue regenerate, per site  teeth #2, 3 and 
bone replacement graft  teeth #2, 3 is not covered under the member's benefit plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
guided tissue regenerate, per site  teeth #2, 3 and bone replacement graft  teeth #2, 3.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87500, 87511, and 87798 provided on May 
2, 2022. 
 
You asked the Plan to pay for procedure codes 87500, 87511, and 87798. 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 
as billed.  
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
We find that procedure code 87500 has an MUE value of 1 unit per day. The record shows that more than one 
unit of this code was reported. Procedure code 87511 has an MUE value of 1 unit per day. The record shows 
that more than one unit of this code was reported. Procedure code 87798 has an MUE of 13 per day. The record 
shows that more than 13 units of this code was reported. Therefore, we decided that the Plan does not have to 
pay for procedure codes 87500, 87511, and 87798 provided on May 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral-complete series of radiographic images provided on 
May 2, 2022. 
 
You asked the Plan to pay for the dental services. 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 April 11, 2022. 
Therefore, we decided that the Plan does not have to pay for intraoral-complete series of radiographic images  
provided on May 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation - problem focused tooth #01 and 32 
(D0140) provided on May 13, 2022. 
 
You asked the Plan to pay for the dental services. You say that the dentist's office coded the claim incorrectly. 
The claim was for a follow-up to a previous appointment addressing an ongoing problem. The Plan denied your 
request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service March 14, 2022.  Therefore, we decided that the Plan does not have to pay for a limited oral evaluation - problem focused tooth 
#01 and 32 (D0140) provided on May 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for consultation - diagnostic service 
provided by dentist or physician other than requesting dentist or physician (D9310) provided May 2, 2022, and 
the bone replacement graft for ridge preservation - per site (D7953), and extraction, erupted tooth requiring 
removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210) 
provided May 24, 2022, by an out-of-network (OON) provider). 
 
You asked the Plan to provide additional payment for the dental consultation, bone replacement graft and tooth 
extraction. You say that you would like these services covered. The Plan denied your request. The Plan says the 
cost=sharing has correctly applied to the tooth extraction. The remaining services are 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 dental consultation and bone 
replacement graft are not among those covered under this benefit. You have been asked to pay 50% 
coinsurance plus the difference between the out-of-network providers charges and the Plans payment for the 
dental extraction. 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 provide additional payment for consultation - diagnostic 
service provided by dentist or physician other than requesting dentist or physician (D9310) provided May 2, 
2022, and the bone replacement graft for ridge preservation - per site (D7953), and extraction, erupted tooth 
requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if 
indicated (D7210) provided May 24, 2022, by an out-of-network (OON) provider).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lower partial denture-cast metal framework with resin 
denture base (D5214) and top or bottom full-arch hard occlusal guard (D9944). 
 
You asked the Plan to pre-approve dental services. You say that you are missing several teeth and need this 
service. 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. Covered routine Dental 
Benefits include lower partial denture-cast metal framework with resin denture base  one procedure every five 
plan years and top or bottom full-arch hard occlusal guard  one procedure every three plan years. 
 
We looked at the file, the Plans rules, and Medicares rules. You previously received covered lower partial 
denture-cast metal framework with resin denture base on March 22, 2021, and received covered top or bottom 
full-arch hard occlusal guard on February 15, 2021. Therefore, we decided that the Plan does not have to pre-
approve lower partial denture-cast metal framework with resin denture base (D5214) and top or bottom full-
arch hard occlusal guard (D9944).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown - porcelain/ceramic (D2740) provided April 11, 
2022. 
 
You asked the Plan to pay for the crown. You say that a TV advertisement indicated that Medicare would cover 
crowns. 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 crown 
- porcelain/ceramic (D2740) provided April 11, 2022.  
 
Your complaint about feeling that the Plan does not adequately inform you about your coverage options 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the recliner chair (A9270). 
 
You asked the Plan to pre-approve the recliner chair. You say that you are appealing the denial of the requested 
recliner chair. The Plan denied your request. The Plan says a recliner chair is not considered durable medical 
equipment because it is not primarily medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve the recliner chair (A9270).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the crowns (D2740 x 19) provided on May 17, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you should be reimbursed the full $2,000 
dental allowance amount. The Plan denied your request. The Plan says your benefit for crowns has been 
exhausted. The Plan also says that you are responsible for any charged amount above the Plans cost-sharing 
amount when your services are received from an out-of-network provider. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you were reimbursed the allowed amount of $1,356 for crowns on tooth #7 and 8. Therefore, 
you have been reimbursed the correct amount. The record also shows your benefit for crowns was exhausted on 
date of service May 17, 2022. You may be asked to pay the difference between the out-of-network providers 
charges and the Plans payment. 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 more for the crowns (D2740 x 19) provided on May 
17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gingivectomy or gingivoplasty to allow access for a 
restorative procedure, per tooth (teeth 9 and 22). 
 
You asked the Plan to pre-approve gingivectomy or gingivoplasty to allow access for a restorative procedure, 
per tooth (teeth 9 and 22). The Plan denied your request. The Plan says gum surgery for restorative procedure 
for teeth 9 and 22 are not covered under 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 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 
gingivectomy or gingivoplasty to allow access for a restorative procedure, per tooth (teeth 9 and 22).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the bitewing x-rays (D0274) provided on May 12, 
2022. 
 
You asked the Plan to reimburse you for the dental service. You say that you should not have to pay this bill. 
You say that the previous x-rays you received should not have been paid. You say that that provider did not do 
their job correctly. You also say that the new dentist should be paid instead. The Plan denied your request. The 
Plan says your benefit for the bitewing x-rays 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 bitewing x-rays was exhausted on date of service May 10, 2022. Therefore, we 
decided that the Plan does not have to reimburse you for the bitewing x-rays (D0274) provided on May 12, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implant supported porcelain/ceramic crowns  
(D6065 x 11) and prefabricated abutmentsincludes modification and placement (D6056 x 11). 
 
You asked the Plan to pre-approve these dental items. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says the requested dental items are not covered under the 
enrollee's contractual policy. 
 
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 are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve implant 
supported porcelain/ceramic crowns (D6065 x 11) and prefabricated abutmentsincludes modification and 
placement (D6056 x 11).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on May 31, 
2022. 
 
You asked the Plan to pay for the dental service. You say that your filling fell out. You say that you were 
advised to go to the emergency room due to choking on it. You also say that the provider office never advised 
they were out-of-network. The Plan denied your request. The Plan says your benefit for the limited oral 
evaluation 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 limited oral evaluation was exhausted on date of service May 27, 2022. Therefore, 
we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on May 31, 
2022.