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

 
We decided that the Plan does not have to pay for periapical radiographic imaging (D0230) provided by a 
participating provider on January 13, 2022. 
 
You asked the Plan to pay for periapical radiographic imaging. You say that you feel like the Plan should pay 
for this. The Plan denied your request. The Plan says the benefit limit for D0230 has 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 one periapical 
radiographic imaging per year. 
 
We looked at the file and Medicare rules. The first periapical radiographic image was covered on the date of 
service in question. All additional images were not covered. Based on this information, we decided that the 
Plan's rules for coverage of periapical radiographic imaging have not been met. Therefore, we decided that the 
Plan does not have to pay for periapical radiographic imaging (D0230) provided by a participating provider on 
January 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction (92015) provided on September 30, 2021. 
 
You asked the Plan to pay for the eye refraction. You say that you did not realize you needed a referral for 
these services. The Plan denied your request. The Plan says they have agreed to reprocess and cover the 
medical eye exam (92004) provided on September 30, 2021, but eye refractions are only covered when they are 
received from a provider in the Plan's routine vision vendor network as part of a routine (non-medical) eye 
exam. Therefore, the refraction remains denied. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when they are performed by a provider in the specified routine vision 
vendor network as part of a routine eye exam. 
 
We looked at the file and the Plan's rules. The eye refraction in this case was performed by a provider who is 
not part of the routine vendor network as part of an eye exam which was billed as a medical exam with medical 
diagnoses. Based on this information, we decided that the Plan's rules for coverage of the eye refraction have 
not been met. Therefore, we decided that the Plan does not have to pay for the eye refraction (92015) provided 
on September 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gingival irrigation  per quadrant (D4921), localized 
delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth 
(D4381), periodontal scaling and root planing - four or more teeth per quadrant (D4341), and core buildup, 
including any pins when required (D2950) provided October 29, 2021, to November 3, 2021. 
 
You asked the Plan to pay for the gingival irrigation, localized delivery of antimicrobial agents, periodontal 
scaling and root planing and core buildup. You say that you were told that you had a $3,000 dental allowance. 
The Plan denied your request. The Plan says you have exhausted your annual limit. 
 
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 gingival 
irrigation, localized delivery of antimicrobial agents, periodontal scaling and root planing and core buildup up to $500 every year.  
 
We looked at the file and Medicare rules. The Plan provided documentation showing that your full $500 dental 
allowance was applied to your dental claims provided October 27, 2021, and October 29, 2021.  Therefore, we 
decided that the Plan does not have to pay for the gingival irrigation  per quadrant (D4921), localized delivery 
of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth (D4381), 
periodontal scaling and root planing - four or more teeth per quadrant (D4341), and core buildup, including any 
pins when required (D2950) provided October 29, 2021, to November 3, 2021.  
 
Your complaint about potentially being provided misinformation about your annual maximum amount 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 the in network rate for the oral exam (D0120), prophylaxis 
(D1110), and bitewing x-rays (D0274) provided on January 11, 2022, by an out of network provider. 
 
You asked the Plan to pay the in network rate for the dental services. You say that you were advised when you 
signed up for this plan that the office was covered. You say that had you known the provider was not covered, 
you would have kept your old insurance. You also say that the services should be paid in full. The Plan denied 
your request. The Plan says additional payment will not be made for the services. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and the services are listed as covered, 
dental services you receive out of network have a higher cost share amount. This is a contractual obligation you agreed to when you enrolled in the Plans dental coverage. Therefore, we decided that the Plan does not have to 
pay the in network rate for the oral exam (D0120), prophylaxis (D1110), and bitewing x-rays (D0274) provided 
on January 11, 2022, by an out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture (dental code D5225). 
 
You asked the Plan to pre-approve partial denture D5225. You say that you have no upper teeth and have a 
hard time biting and chewing. The Plan denied your request. The Plan says this type of partial denture 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. The Plans dental benefits include coverage for partial dentures, but 
not for the requested partial denture code D5225. Therefore, we decided that the Plan does not have to pre-
approve a maxillary partial denture (dental code D5225).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), radiographic 
imaging (D0210), panoramic radiographic images (D0330), and a resin-based composite (D2331), provided by 
an out-of-network provider on March 17, 2022. 
 
You asked the Plan to pay for a comprehensive oral evaluation radiographic imaging, panoramic radiographic 
images, and a resin-based composite. You say that you were told that you would not pay anything out-of-
pocket. The Plan denied your request. The Plan says this claim has been 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. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a comprehensive oral evaluation radiographic imaging, panoramic radiographic images, and a 
resin-based composite have not been met. Therefore, we decided that the Plan does not have to pay for a 
comprehensive oral evaluation (D0150), radiographic imaging (D0210), panoramic radiographic images 
(D0330), and a resin-based composite (D2331), provided by an out-of-network provider on March 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal scaling and root planing - four or more teeth 
per quadrant (D4341) provided December 13, 2021, and December 21, 2021. 
 
You asked the Plan to pay for the periodontal scaling and root planing. You say that cleanings are covered 
under your plan. 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 
periodontal scaling and root planing - four or more teeth per quadrant (D4341) provided December 13, 2021, 
and December 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction (D7210) and trigeminal division block 
anesthesia (D9212) provided on February 8, 2022. 
 
You asked the Plan to pay for the dental services. You say that the provider you saw was in network. You say 
that you have had this same procedure before with the same dentist and it covered. You say that you feel 
coverage is being taken from you over the years. You also say that you do not understand why at least part of 
this bill is not covered. The Plan denied your request. The Plan says the claim was denied correctly. 
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the extraction and trigeminal division 
block anesthesia are not among those covered under this benefit. Additionally, the change in coverage was 
communicated in the Annual Notice of Changes for 2022. Therefore, we decided that the Plan does not have to 
pay for the extraction (D7210) and trigeminal division block anesthesia (D9212) provided on February 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the 7 surgical extractions (D7210) provided on 
November 9, 2021. 
 
You asked the Plan to reimburse you for the dental services. You say that it was determined the enrollee had an 
infection and needed teeth to be extracted. You say that the enrollee was given 7 days of antibiotics for the 
infection. You say that the enrollee could not have their other surgery with infection present. You also say that 
the extractions were medically necessary. The Plan denied your request. The Plan says oral surgery is limited to 
simple extractions. The Plan also says that surgical extractions are excluded from Medicare coverage unless 
part of another covered 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the surgical extractions are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for the 7 
surgical extractions (D7210) provided on November 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (82310, 82728, 83540, 83550, 84100) 
provided on December 8, 2021. 
 
You asked the Plan to pay for laboratory services. You say that there is no agreement in place to include these 
services in the dialysis rate. The Plan denied your request. The Plan says these services are not separately 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that all laboratory services furnished to individuals 
for the treatment of end-stage renal disease (ESRD) are included in the ESRD Prospective Payment System 
(PPS) as Part B services and are not paid separately. 
 
 We looked at the file and Medicare rules. The laboratory services at issue were provided for the treatment of 
ESRD. Based on this information, we decided that Medicare rules for coverage of laboratory services have not 
been met Therefore, we decided that the Plan does not have to pay for laboratory services (82310, 82728, 
83540, 83550, 84100) provided on December 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an opt-out provider on 
November 22, 2021. 
 
You asked the Plan to pay for dental services. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says the rendering dentist has opted-out of Medicare. 
 
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 until July 1, 2023. Therefore, we decided that the Plan does not have to 
pay for dental services provided by an opt-out provider on November 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nutritional counseling (D1310) and periodontal 
maintenance (D4910) provided on February 1, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be paid. The Plan denied 
your request. The Plan says the nutritional counseling and periodontal maintenance are not listed as covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the nutritional counseling and 
periodontal maintenance are not among those covered under this benefit. Therefore, we decided that the 
Plan does not have to pay for the nutritional counseling (D1310) and periodontal maintenance 
(D4910) provided on February 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provided reimbursement for the surgical extraction (D7210) and 
bone replacement graft (D7953) provided on December 16, 2021. 
 
You asked the Plan to provided reimbursement for the dental services. You say that you would like the services 
to be covered. The Plan denied your request. The Plan says the services are not covered. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to provided reimbursement for involve the care, treatment, filling, removal 
or replacement of the enrollee's teeth or the structures directly supporting the enrollee's teeth. These are dental 
services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to provided reimbursement for the surgical extraction (D7210) and bone replacement graft (D7953) provided on December 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for the crown - porcelain/ceramic 
(D2740) provided December 7, 2021. 
 
You asked the Plan to provide additional payment for the crown. You say that when you signed up for the Plan 
you were told you had a $2,000 dental maximum. The Plan denied your request. The Plan says you have 
exhausted your dental maximum and no further payment is due. 
 
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 crowns up to 
a maximum allowance of $1,250. 
 
We looked at the file and Medicare rules. The Plan provided documentation showing that at the time the claim for the crown was processed you had $549 remaining in your maximum allowance for supplemental dental 
services. This amount was applied to your claim. You have been asked to pay the remaining amount above the 
maximum allowance. This means you have been asked to pay the correct amount based on your contract with 
the Plan. Therefore, we decided that the Plan does not have to provide additional payment for the crown - 
porcelain/ceramic (D2740) provided December 7, 2021.  
 
Your complaint about potentially being provided misinformation when you signed up for the Plan 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 oral hygiene instructions (D1330), an unspecified procedure 
(D9999), a limited oral evaluation (D0140), and intraoral imaging (D0220) provided by an out-of-network 
provider on June 22, 2021, to June 24, 2021. 
 
You asked the Plan to pay for oral hygiene instructions, an unspecified procedure, a limited oral evaluation, 
and intraoral imaging. You say that you believe these services should be covered. The Plan denied your 
request. The Plan says the rendered services 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. 
 
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 oral 
hygiene instructions (D1330), an unspecified procedure (D9999), a limited oral evaluation (D0140), and 
intraoral imaging (D0220) provided by an out-of-network provider on June 22, 2021, to June 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an out-of-network provider on 
January 26, 2022. 
 
You asked the Plan to pay for dental services. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says services provided by an out-of-network provider 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. The Plan covers covered 
dental services when the services are provided by a participating provider. 
 
We looked at and Medicare rules. The rendering dentist is out-of-network. Based on this information, we 
decided that the Plan's rules for coverage of dental services have not been met. Therefore, we decided that the 
Plan does not have to pay for dental services provided by an out-of-network provider on January 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown - porcelain/ceramic (D2740) for tooth 19. 
 
You asked the Plan to pre-approve a crown. You say that this dental work is not cosmetic, it is necessary to 
keep your tooth intact. 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 pre-approve a 
crown - porcelain/ceramic (D2740) for tooth 19.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gingival irrigation  per quadrant (D4921) and drugs or 
medicaments dispensed in the office for home use (D9630). 
 
You asked the Plan to pre-approve gingival irrigation and drugs dispensed in the office for home use. You say 
that the enrollee needs these services. The Plan denied your request. The Plan says these services are not 
covered under the enrollee's 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 
gingival irrigation  per quadrant (D4921) and drugs or medicaments dispensed in the office for home use 
(D9630).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visits (99212) manual therapy 
techniques (97140) infrared therapy (97026) provided March 18, 2021 to December 16, 2021. 
 You asked the Plan to pay for the acupuncture services. You say that you were referred for acupuncture 
treatments by your primary care physician. You were approved for 20 visits. Prior to your first visit, the 
provider called the Plan to verify coverage and the number of visits. The Plan denied your request. The Plan 
says these services are not covered benefits. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plans rules apply in this case.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, office visits, manual therapy techniques and infrared 
therapy are not covered under the Plan benefits. Therefore, we decided that the Plan does not have to pay for 
the outpatient office visits (99212) manual therapy techniques (97140) infrared therapy (97026) provided 
March 18, 2021 to December 16, 2021.