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

 
We decided that the Plan does not have to waive the cost sharing for an extraction, erupted tooth requiring 
removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated tooth #'s 
4, 5 (D7210), extraction, erupted tooth or exposed root (elevation and/or forceps removal) tooth #'s 4, 5 
(D7140), intraoral - complete series of radiographic images (D0210), and limited oral evaluation - problem 
focused (D0140) provided on July 14, 2022. 
 You asked the Plan to waive the cost sharing for the dental services. You say that you feel the services should 
be covered because they are a covered benefit under your benefits. The Plan denied your request. The Plan says 
you have been charged the correct cost sharing amount. 
 
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 contract says you 
pay 50% coinsurance after $100 deductible for a Class 2 basic service(s) and a Class 3 major service(s). 
 
You have been asked to pay a total of $271.50. 
 
 
SERVICE 
ALLOWED 
AMOUNT 
 
DEDUCTIBLE 
 
COINSURANCE 
MEMBER 
RESPONSIBILITY 
D0140  Class 2 $65.00 $65.00  $65.00 
D0210  Class 2 $118.00 $35.00 50% $76.50 
D7210 tooth #4  Class 2 
Favorable 
Lower cost 
alternative 
  $0 
D7210 tooth #5  Class 2 
Favorable 
Lower cost 
alternative 
  $0 
D7140 tooth #5  Class 3 $130.00  50% $65.00 
D7140 tooth #4  Class 3 $130.00  50% $65.00 
TOTAL    $271.50 
 
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 cost sharing for an extraction, erupted tooth requiring removal of bone 
and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated tooth #'s 4, 5 (D7210), 
extraction, erupted tooth or exposed root (elevation and/or forceps removal) tooth #'s 4, 5 (D7140), intraoral - 
complete series of radiographic images (D0210), and limited oral evaluation - problem focused (D0140) 
provided on July 14, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a dental cleaning (D1110) 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says that your benefit for the requested item or 
service has already been exhausted but did not provide proof that you received a cleaning within the last 6 
months. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. There is no evidence showing your benefit for the requested item or service was previously 
exhausted. Therefore, we decided that the Plan has to pre-approve a dental cleaning (D1110)  
 
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 pre-approve a pontic on tooth #19 (D6245) and retainer crowns on 
tooth #18 and 20 (D6740). 
 
You asked the Plan to pre-approve a pontic and crowns. You say that you want the Plan to reconsider 
approving these services. The Plan denied your request. The Plan says a pontic (D6245) and retainer crowns 
(D6740) are not covered by your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
pontic on tooth #19 (D6245) and retainer crowns on tooth #18 and 20 (D6740).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance provided on May 17, 2022. 
 
You asked the Plan to pay for dental services. You say that you should not pay for this service because you 
were ordered by the provider to have this done. The Plan denied your request. The Plan says this is covered 
with a $100 deductible and 50% coinsurance. If you choose to use an out-of-network provider, you may be 
billed a higher amount. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. This benefit includes 
periodontal cleaning once every 6 months following active periodontal therapy, not to be combined with 
regular cleanings. You pay 50% coinsurance after $100 deductible for Class 2 Basic Services. 
 
  We looked at the file, the Plans rules, and Medicares rules. Provider billed $150 for Periodontal Maintenance, 
the allowed amount is $105, the ineligible amount is $45, your deductible is $100, which had not been met at 
the time of services, the coinsurance is 50% of the remaining $5 from the allowed amount is $2.50 ($45 + $100 
+ $2.50 = $147.50). Your total responsibility is $147.50. Therefore, we decided that the Plan does not have to 
pay for periodontal maintenance provided on May 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for removal of torus mandibularis (D7473) 
provided on February 25, 2022. 
 
You asked the Plan to waive the coinsurance for the removal of torus mandibularis (D7473). You say that you 
were very mis-informed. The Plan denied your request. The Plan says you have been charged the correct cost 
sharing amount. 
 
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 contract states there 
is a 50% coinsurance for each Medicare-covered out-of-network dental service. 
 
 
  
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 removal of torus mandibularis (D7473) provided on 
February 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on June 21, 2022. 
 
You asked the Plan to pay for the panoramic x-ray. The Plan denied your request. The Plan says this service is 
not covered under your plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
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 
panoramic x-ray (D0330) provided on June 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two periodontal scalings and root planings (D4341 x2) 
and local anesthesia (D9210) provided on August 17, 2022. 
 
You asked the Plan to pay for the scalings and planings and local anesthesia. You say that these procedures 
were required, and you would like them to be covered under your dental plan. The Plan denied your request. 
The Plan says these services 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 pay for the two 
periodontal scalings and root planings (D4341 x2) and local anesthesia (D9210) provided on August 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown (D2740) provided on July 20, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the crown. You say that you made every effort to use an in-network dentist for 
your dental emergency, and have clear evidence that the provider who treated you is an in-network dentist. The 
Plan denied your request. The Plan says the dental services were received from an out-of-network provider and 
are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 
 
 
 The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Specifically, this service was not rendered at either 
location the treating provider's name is listed under in the Plan's Provider Directory. Therefore, we decided that 
the Plan does not have to pay for the crown (D2740) provided on July 20, 2022, by an out-of-network (OON) 
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for core buildup, including any pins when 
required (D2950) and a porcelain crown fused to predominately base metal (D2751) provided on June 30, 
2022. 
 
You asked the Plan to waive the coinsurance for core buildup, including any pins when required (D2950) and a 
porcelain crown fused to predominately base metal (D2751). You say that you received information about a 
denial for crowns. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 50% 
coinsurance for after $100 deductible for Class 2 basic dental services.  
 
You have been asked to pay $104.50 in coinsurance, which is 50% of the allowed amount for core buildup, 
including any pins when required (D2950) ($209 allowed amount x 50% coinsurance = $104.50). You have 
also been asked to pay $428.50 in coinsurance, which is 50% of the allowed amount for a porcelain crown 
fused to predominately base metal (D2751) ($857 allowed amount x 50% coinsurance = $428.50). Plus, you 
have also been asked to pay the $76 difference in the allowed amounts for the crown ($933 dentist charge - 
$857 allowed amount = $76). These services fall within the after Class 2 basic 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 core buildup, including any pins when required (D2950) 
and a porcelain crown fused to predominately base metal (D2751) provided on June 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral exam (D0150) provided on June 29, 
2022. 
 
You asked the Plan to pay for the dental services. You say that you changed providers because you did not feel 
comfortable with the previous provider. 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 October 21, 2021. 
Therefore, we decided that the Plan does not have to pay for the comprehensive oral exam (D0150) provided 
on June 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive periodontal evaluation (D0180) provided 
on June 1, 2022. 
 
You asked the Plan to pay for the comprehensive periodontal evaluation. You say that the services should be 
covered as you disagree with the denial. The Plan denied your request. The Plan says the services denied 
correctly as they do not fall within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
comprehensive periodontal evaluation (D0180) provided on June 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an occlusal guard  hard appliance, full arch (D9944). 
 
You asked the Plan to pre-approve the occlusal guard  hard appliance, full arch (D9944). The Plan denied 
your request. The Plan says this service is not covered under the benefit package. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
occlusal guard  hard appliance, full arch (D9944).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 70450 billed for date of service August 15,
2022.
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for
code 70496.
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, we have confirmed that code 70450
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we
decided that the Plan does not have to pay for procedure code 70450 billed for date of service August 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete lower denture (D5120). 
 
You asked the Plan to pre-approve the dental service. You say that you lost your dentures and need a new one. 
The Plan denied your request. The Plan says your benefit for the requested item or service has already been 
exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on the date of service of April 17, 2019. 
Therefore, we decided that the Plan does not have to pre-approve a complete lower denture (D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pin retention - per tooth, in addition to restoration (D2951) 
provided on July 19, 2022. 
 
You asked the Plan to pay for the dental services. You say that you broke your tooth and did not know fixing it 
was not part of the Plan benefits. The Plan denied your request. The Plan says the dental services were received 
from an out-of-network provider and are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for pin retention - per tooth, in addition to restoration (D2951) provided on July 19, 2022.  The Plan 
agreed to reprocess the resin-based composite - four or more surfaces, posterior (D2394) per the in-network 
benefits as a one-time courtesy.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided on June 11, 2021, billed with codes 81479, 81406, 81223, 81226,  81225, 81306, 81401, 81350, 81328, 81335, 81227, 81230, 81231, 81232, 81400, 81241, 
81291, and 81240.

You asked the Plan to pay for the genetic testing billed. You say that you disagree with the denial. The Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim.

The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or proprietary laboratory analysis code.

We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on June 11, 2021, billed with codes 81479, 81406, 81223, 81226,  81225, 81306, 81401, 81350, 81328, 81335, 81227, 81230, 81231, 81232, 81400, 81241, 
81291, and 81240.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay in full for the crown (D2740) provided on April 20, 2022. 
 
You asked the Plan to pay in full for the crown. You say that you feel this service should be paid in full by the 
Plan. The Plan denied your request. The Plan says your $1,000 benefit max was met with the processing of the 
appealed claims. 
 
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 offers a $1,000 annual dental 
benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are 
responsible for the full charges of any additional dental services. The record shows that you met the annual 
maximum benefit while processing this claim for the April 20, 2022, date of service and your annual maximum 
benefit has been exhausted. Therefore, we decided that the Plan does not have to pay in full for the crown 
(D2740) provided on April 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87640 billed for date of service November 1, 
2021. 
 
You asked the Plan to pay for procedure code 87640. You say that these services were denied in error. The 
Plan denied your request. The Plan says payment for code 87640 is bundled into payment for code 87641. 
 
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, we have confirmed that code 87640 
is a column II code to column I code 87641. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 87640 billed for date of service November 1, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gingival irrigation per quadrant (D4921) provided on July 8, 
2022. 
 
You asked the Plan to pay for dental services. You say that the provider did not do a great job and you would 
like the Plan to pay for the service. The Plan denied your request. The Plan says this service is not covered 
under your Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. Gingival irrigation per 
quadrant (D4921) is not covered under the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested gingival irrigation per 
quadrant (D4921) is not among those covered under this benefit. Therefore, we decided that the Plan does not 
have to pay for gingival irrigation per quadrant (D4921) provided on July 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided by a participating 
provider on July 14, 2022. 
 
You asked the Plan to pay for the dental services. You say that each dentist needed to exam your tooth. The 
Plan denied your request. The Plan says your benefit for the requested item or service has already been 
exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service July 12, 2022. Therefore, 
we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided by a participating 
provider on July 14, 2022.