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

 
We decided that the Plan does not have to pre-approve a maxillary denture, mandibular denture, and 21 
extractions. 
 
You asked the Plan to pre-approve a maxillary denture, mandibular denture, and 21 extractions. You say that 
the extractions and dentures are medically necessary due to the enrollee's cancer treatment. The Plan denied 
your request. The Plan says two of the 23 extractions are approved and the remaining 21 extractions are denied 
due to frequency limitations. The Plan also says there is no coverage for the immediate dentures as the service 
is not listed in the Supplemental Dental Benefit chart.   
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 
maxillary immediate denture (D5130), mandibular immediate denture (D5140), and 21 simple extractions 
(D7140 x21).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an interim partial denture (D5821) provided on March 3, 2022. 
 
You asked the Plan to pay for the interim partial denture. 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an interim 
partial denture (D5821) provided on March 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on February 22, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service provided in this case is 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the service provided is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral 
evaluation (D0140) provided on February 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gingival irrigation (D4921) provided by a participating 
provider. 
 
You asked the Plan to pre-approve gingival irrigation. You say that you would like the Plan to approve these 
services. The Plan denied your request. The Plan says the requested dental service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
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 (D4921) provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950) 
provided February 8, 2022. 
 
You asked the Plan to pay for the core buildup. You say that this service was necessary and should be covered 
by the 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 core 
buildup, including any pins when required (D2950) provided February 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an occlusal guard (D9945). 
 
You asked the Plan to pre-approve an occlusal guard. You say that you disagree with the denial for a mouth 
guard for teeth grinding. The Plan denied your request. The Plan says an occlusal guard is 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 an 
occlusal guard (D9945).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of torus mandibularis (D7473). 
 
You asked the Plan to pre-approve the removal of torus mandibularis. You say that you need this service to 
make your dentures fit properly. The Plan denied your request. The Plan says removal of torus mandibularis 
(D7473) is not covered by your routine 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 the 
removal of torus mandibularis (D7473).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement graft (D7953), biological materials 
(D4265), and an endosteal implant (D6010), provided by a participating provider. 
 
You asked the Plan to pre-approve a bone replacement graft, biological materials, and an endosteal implant. 
You say that you would like approval for these services. The Plan denied your request. The Plan says dental 
implants and all related services are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit.  
 
Therefore, we decided that the Plan does not have to pre-approve a bone replacement graft (D7953), biological 
materials (D4265), and an endosteal implant (D6010), provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a porcelain/ceramic crown on January 20, 2022. 
 
You asked the Plan to pay for a porcelain/ceramic crown. You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says according to the EOC, the 
plan does not provide benefits to restore damage due to attrition, abrasion, erosion, or abfraction. 
 
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 
porcelain/ceramic crown on January 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller 
and two or more power seating system motors (E2311), a harness for upgrade to an expandable controller 
(E2313) and an expandable controller (E2377). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that without the recline feature, you would 
have to sit permanently at 90 degrees, which you have been unable to do for months due to spasticity. The 
recline would allow you to do so gradually and relax when needed. The expandable controls are needed to 
power this function through the joystick, and it is also necessary that you have that so you can reach it and not 
hinder the support and rehabilitation of your spine and back. The Plan denied your request. The Plan says there 
is not a medical need to control these power options through the joystick. 
 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 an electronic connection between wheelchair controller and 
two or more power seating system motors (E2311), a harness for upgrade to an expandable controller (E2313) 
and an expandable controller (E2377).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation on February 16, 2022. 
 
You asked the Plan to pay for a limited oral evaluation. You say that you would like to appeal the denial of the 
claim. The Plan denied your request. The Plan says an x-ray and medical records are required, and they weren't 
received. 
 
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 if an x-ray isnt received beforehand. Therefore, we decided that the 
Plan does not have to pay for a limited oral evaluation on February 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a 2D oral/facial photographic image and diagnostic cast 
(D0350, D0470) provided on January 11, 2022. 
 
You asked the Plan to pay for the 2D oral/facial photographic image and diagnostic cast. 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 2D 
oral/facial photographic image and diagnostic cast (D0350, D0470) provided on January 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical placement of implant body (dental code 
D6010) and porcelain fused to metal crown (dental code D6061) for tooth #31. 
 
You asked the Plan to pre-approve the surgical placement of implant body and porcelain fused to metal crown. 
You say that you need these services so it can help you with your health and digestion. The Plan denied your 
request. The Plan says these services are 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. Therefore, we decided that the Plan does not have to pre-approve the 
surgical placement of implant body (dental code D6010) and porcelain fused to metal crown (dental code 
D6061) for tooth #31.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve i-Factor Allograft (20930). 
 
You asked the Plan to pre-approve i-Factor Allograft. You say that the requested service is medically 
necessary. The Plan denied your request. The Plan says the service at issue is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve i-Factor Allograft. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is limited published, large-scale, long-term peer-reviewed literature that shows 
this request to be an effective and/or safe treatment for the noted pathology. The requested i-Factor has not 
been proven efficacious for use in the lumbar spine. There is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of i-Factor Allograft have not been met. Therefore, we decided that the Plan does 
not have to pre-approve i-Factor Allograft (20930).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the add tooth to existing partial denture (D5650), extraction, 
erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal 
flap if indicated (D7210) and reline maxillary partial denture (indirect) (D5760) provided June 7, 2021. 
 
You asked the Plan to pay for the add tooth to existing partial denture, surgical extraction and reline upper 
partial denture. You say that you were not informed the services would not be covered. The Plan denied your 
request. The Plan says these 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the add 
tooth to existing partial denture (D5650), extraction, erupted tooth requiring removal of bone and/or sectioning 
of tooth and including elevation of mucoperiosteal flap if indicated (D7210) and reline maxillary partial 
denture (indirect) (D5760) provided June 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endosteal implant on tooth #23 and 26 (D6010), 
prefabricated abutments on tooth #22 and 23 (D6056), and therapeutic parenteral drugs (D9612). 
 
You asked the Plan to pre-approve implants, abutments, and parenteral drugs. You say that the implants are 
medically necessary and will improve your quality of life. The Plan denied your request. The Plan says these 
services are not covered by your Plan's routine 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 an 
endosteal implant on tooth #23 and 26 (D6010), prefabricated abutments on tooth #22 and 23 (D6056), and 
therapeutic parenteral drugs (D9612).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services on January 24, 2022. 
 
You asked the Plan to pay for dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says we have reprocessed extraction (D7210) erupted 
tooth requiring removal of bone x2 services at your out-of- network benefit of 45%. Our records indicate there 
were two extractions, erupted tooth requiring removal of bone that were already issued for reimbursement. 
Reimbursement was previously issued for the same date of service 01/24/2022. Therefore, that benefit has been 
exhausted. Our records indicate you did contact the plan prior to the date of service to verify benefits and 
provider eligibility. You did verify that you had OON coverage and so the claim was reprocessed according to 
your OON 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 fully covered under this benefit if they are received OON. Therefore, we decided that the Plan 
does not have to pay for dental services on January 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950) 
provided May 6, 2021. 
 
You asked the Plan to pay for the core buildup. You say that the cost of the services was higher than the 
provider estimated because this service was denied. 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 core 
buildup, including any pins when required (D2950) provided May 6, 2021.  
 
Your complaint about your initial quoted cost not matching the actual cost of the services 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 bone replacement graft for ridge preservation - per site 
(D7953), cone beam computed tomography (CT) capture and interpretation with limited field of view  less 
than one whole jaw (D0364) and guided tissue regeneration - resorbable barrier, per site (D4266) provided 
February 9, 2022. 
 
You asked the Plan to pay for the bone replacement graft, cone beam CT scan and guided tissue regeneration. 
You say that these services were essential to your dental needs. The Plan denied your request. The Plan says 
these 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 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 bone 
replacement graft for ridge preservation - per site (D7953), cone beam computed tomography (CT) capture and 
interpretation with limited field of view  less than one whole jaw (D0364) and guided tissue regeneration - 
resorbable barrier, per site (D4266) provided February 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve drugs or medicaments dispensed in the office for home 
use (D9630). 
 
You asked the Plan to pre-approve these 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 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 drugs or 
medicaments dispensed in the office for home use (D9630).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete maxillary dentures (D5110) and partial 
mandibular dentures (D5214). 
 
You asked the Plan to pre-approve dentures. You say that you disagree with the denial for dental services. The 
Plan denied your request. The Plan says complete maxillary dentures (D5110) and partial mandibular dentures 
(D5214) 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 
complete maxillary dentures (D5110) and partial mandibular dentures (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing, localized delivery of 
antimicrobial agents, gingival irrigation, and the application of desensitizing medicament (D9910, D4921, 
D4341, D4381) provided on April 7, 2022. 
 
You asked the Plan to pay for the periodontal scaling and root planing, localized delivery of antimicrobial 
agents, gingival irrigation, and the application of desensitizing medicament. 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
periodontal scaling and root planing, localized delivery of antimicrobial agents, gingival irrigation, and the 
application of desensitizing medicament (D9910, D4921, D4341, D4381) provided on April 7, 2022.