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

 
We decided that the Plan does not have to pay for the intraoral - periapical first radiographic image (D0220), 
intraoral - periapical each additional radiographic image (D0230), and adjunctive pre-diagnostic test that aids in 
detection of mucosal abnormalities including premalignant and malignant lesions, not to include cytology or 
biopsy procedures (D0431) provided on June 28, 2022 
 
You asked the Plan to pay for the intraoral x-rays and adjunctive pre-diagnostic test. You say that these 
services should be covered as preventative services. 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 
intraoral - periapical first radiographic image (D0220), intraoral - periapical each additional radiographic image 
(D0230), and adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities including 
premalignant and malignant lesions, not to include cytology or biopsy procedures (D0431) provided on June 
28, 2022
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical implant (D6010), implant support crown 
(D6066), and an osseous graft (D7950) for tooth #10. 
 
You asked the Plan to pre-approve the dental services. You say that it is necessary to get these services done 
because you are in pain. The Plan denied your request. The Plan says the denial of authorization for these 
services is correct, because implants and osseous grafts are not covered by the 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 the 
surgical implant (D6010), implant support crown (D6066), and an osseous graft (D7950) for tooth #10.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a localized delivery of antimicrobial agents (D4381) 
provided on June 28, 2022. 
 
You asked the Plan to pay for the localized delivery of antimicrobial agents. 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 
localized delivery of antimicrobial agents (D4381) provided on June 28, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasonic guidance for placement of radiation therapy 
fields (G6001). 
 
You asked the Plan to pre-approve image guided radiation therapy. You say that due to mitigating factors such 
as tissue mobility and location of the lesion, it was determined that Image-Guided Superficial Radiation 
Therapy (IG-SRT) was medically necessary for this enrollee. The Plan denied your request. The Plan says 
image guided radiation therapy is not medically reasonable or 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 image guided radiation therapy. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found IGRT is a means to improve set-up accuracy. IGRT uses daily image guidance to help localize the target so as to minimize normal tissue dosing. Specifically, IGRT allows accuracy 
of treatment delivery, so when generating a planning target margin, the margins can be reduced, and thus allow 
reduction in the volume of normal tissues exposed to radiation. Usually, IGRT is used when critical structures 
are abutting or in close proximity to the target that is being treated to high doses. This situation does not apply 
to this enrollee for which the target lesion can be seen on the skin to assist in daily set up. When treating skin 
cancers, there is generally not a need for IGRT unless deep structures are being treated. Certainly, using 
ultrasound on a daily basis is not unreasonable to offer but not necessary. Therefore, to bill for daily simple 
simulations and/or IGRT for a technology for which need has not been established by published data or 
supported by consensus guidelines (many of which recommend against treatment with these devices in general- 
citations below) is not necessary.  My decision is unfavorable as billing for daily simulations (also requested in 
this case) or IGRT would not be furnished in accordance with accepted standards of medical practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of image guided radiation therapy have not been met. Therefore, we decided that 
the Plan does not have to pre-approve ultrasonic guidance for placement of radiation therapy fields (G6001).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve clinical crown lengthening (D4249) for tooth number 5, 
and the canal preparation and fitting of preformed dowel or post (D3950) for teeth number 5 and 9. 
 
You asked the Plan to pre-approve clinical crown lengthening (D4249) for tooth number 5, and the canal 
preparation and fitting of preformed dowel or post (D3950) for teeth number 5 and 9. You say that you need 
these crowns. You also say you cannot afford to pay that amount of money. The Plan denied your request. The 
Plan says the canal preparation and fitting of preformed dowel or post (D3950) is not covered under your 
benefit plan. The Plan also says that clinical crown lengthening (D4249) for tooth number 5 is a service that is 
included with the crown, and the dentist does not need to send a separate request for this service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  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 
clinical crown lengthening (D4249) for tooth number 5, and the canal preparation and fitting of preformed 
dowel or post (D3950) for teeth number 5 and 9.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental services. 
 
You asked the Plan to pre-approve the dental services. You say that you would like to request reconsideration 
of the denied authorization. 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 26, 2022. 
Therefore, we decided that the Plan does not have to pre-approve the dental services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown - porcelain fused to high noble metal tooth #10 
(D2750). 
 
You asked the Plan to pre-approve the dental services. You say that you need the crown. You say you can't 
wait to get it approved and you do not have the resources to pay out of pocket. 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 30, 2018. 
Therefore, we decided that the Plan does not have to pre-approve a crown - porcelain fused to high noble metal 
tooth #10 (D2750).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown - porcelain/ceramic tooth #'s 9, 10, 11 (D2740). 
 
You asked the Plan to pre-approve the dental services. You say that the dental services are medically necessary 
for the enrollee. 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 30, 2022. 
Therefore, we decided that the Plan does not have to pre-approve a crown - porcelain/ceramic tooth #'s 9, 10, 
11 (D2740).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4557 billed for date of service April 29, 
2022. 
 You asked the Plan to pay for procedure code A4557. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says procedure code A4557 is considered bundled 
and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code A4557 has a status indicator of P on the Physician Fee Schedule. This means that 
procedure code A4557 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code A4557 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code A4557 billed for date of service April 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental services. 
 
You asked the Plan to pre-approve the dental services.. You say that you would like to request reconsideration 
of the denied authorization. The Plan denied your request. The Plan says the 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 the 
dental services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the guided tissue regeneration (D4266), bone 
replacement graft (D7953), placement of implant body (D6010), fabricated abutment (D6057), and a crown 
(D6058) for tooth #30. 
 
You asked the Plan to pre-approve the dental services. You say that you would like for these dental procedures 
to be approved. The Plan denied your request. The Plan says the denial of authorization for these services is 
correct, because guided tissue regeneration, bone replacement grafts, placement of implant body, fabricated 
abutment, and crowns are not covered by the 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 the 
guided tissue regeneration (D4266), bone replacement graft (D7953), placement of implant body (D6010), 
fabricated abutment (D6057), and a crown (D6058) for tooth #30.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on March 10, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the services requested 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 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 dental 
services on March 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a surgical stent (D5982) provided by a participating provider 
on July 7, 2022. 
 
You asked the Plan to pay for a surgical stent. You say that you needed this dental work done. The Plan denied 
your request. The Plan says the rendered 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 pay for a surgical 
stent (D5982) provided by a participating provider on July 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a surgical removal of erupted tooth (D7210) and an 
alveoloplasty (D7310) provided on August 23, 2022. 
 
You asked the Plan to pay for the dental services. You say that you thought the dental services would be 
covered by the medical portion of the Plan. The Plan denied your request. The Plan says your dental benefit for 
the year was exhausted on the date of 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, certain limitations apply. On January 
3, 2022, the Plan paid $189 for the dental services. On March 3, 2022, the Plan paid $49 for the dental services. 
On March 29, 2022, the Plan paid $1,690 for the dental services. On August 23, 2022, the Plan paid $72 for the 
dental services. The total amount the Plan paid for the yearly dental services was $2,000 ($189 paid + $49 paid 
+ $1,690 paid + $72 paid); therefore, the enrollee hit their yearly dental benefit limit on August 23, 2022. The 
record shows your benefit for the requested item or service was exhausted on date of service August 23, 2022. 
Therefore, we decided that the Plan does not have to pay for a surgical removal of erupted tooth (D7210) and 
an alveoloplasty (D7310) provided on August 23, 2022.  
 
Your complaint about your experience with the provider 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 pre-approve the erupted tooth extraction requiring removal of bone 
and/or sectioning of tooth (D7210) for teeth numbers 5, 6, 8, 9, 12, 13, 14, and 29. 
 
You asked the Plan to pre-approve the erupted tooth extraction requiring removal of bone and/or sectioning of 
tooth (D7210) for teeth numbers 5, 6, 8, 9, 12, 13, 14, and 29. You say that are appealing with supporting 
records. The Plan denied your request. The Plan says they denied this service because the code the member's 
dentist submitted involves cutting of gums and bone for the removal of the tooth. The Plan also says that the 
member's teeth can be removed with a simpler extraction, CDT code D7140, which is the extraction of an 
erupted tooth or exposed root. 
 
  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 erupted 
tooth extraction requiring removal of bone and/or sectioning of tooth (D7210) for teeth numbers 5, 6, 8, 9, 12, 
13, 14, and 29 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 the erupted tooth extraction requiring 
removal of bone and/or sectioning of tooth (D7210) for teeth numbers 5, 6, 8, 9, 12, 13, 14, and 29. Our 
reviewer says that these services are not medically reasonable and necessary. Our physician reviewer found 
these teeth do not require surgical removal as there is full structure of each tooth remaining, and there is 
notable loss of the supporting bone. Our physician reviewer also found that a lesser code for removal without 
surgical cutting would be more appropriate. 
 
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 the erupted tooth extraction requiring removal of bone and/or sectioning of 
tooth (D7210) for teeth numbers 5, 6,8,9,12,13,14, and 29 have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the erupted tooth extraction requiring removal of bone and/or sectioning of 
tooth (D7210) for teeth numbers 5, 6, 8, 9, 12, 13, 14, and 29.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral - periapical each additional radiographic image 
(D0230), periodic oral evaluation - established patient (D0120), bitewings - four radiographic images (D0274), 
prophylaxis - adult (D1110), and intraoral - periapical first radiographic image (D0220) provided on May 18, 
2022. 
 
You asked the Plan to pay for the dental services. You say that your dentist told you they checked the Plan and 
you were covered. You say that when it was time to pay the provider said it was denied and were responsible 
for the charges. 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 an intraoral - periapical each additional radiographic image (D0230), periodic oral evaluation - 
established patient (D0120), bitewings - four radiographic images (D0274), prophylaxis - adult (D1110), and 
intraoral - periapical first radiographic image (D0220) provided on May 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an endosteal implant (D6010), an extraction (D7210), 
unspecified oral surgery (D7999), and the placement of an intra-socket biologic dressing (D7922) provided on 
March 29, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told these services would be covered. 
The Plan denied your request. The Plan says the requested items and 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 pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for an endosteal implant (D6010), an 
extraction (D7210), unspecified oral surgery (D7999), and the placement of an intra-socket biologic dressing 
(D7922) provided on March 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gum graft (41870), dental surgery procedure (41899), and 
office consultation (99242) provided on June 9, 2021. 
 
You asked the Plan to pay for the gum graft, dental surgery procedure, and office consultation. You say that 
you believe this dental surgery should be covered under your medical plan. The Plan denied your request. The 
Plan says these services are not covered by the Plan. The Plan also says that the billed code of 99242 is invalid 
for Medicare purposes. 
 Medicare generally does not cover dental services. The Plan follows the same rule. Medicare rules also say that 
providers must report services correctly. Providers must report services with the appropriate procedure code. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. The record shows that these services were provided due to a decayed tooth which needed to 
be extracted. These services are purely dental in nature. We also find that procedure code 99242 has a Status 
Indicator of I on the Physician Fee Schedule. This means that procedure code 99242 is not valid for Medicare 
purposes. Therefore, we decided that the Plan does not have to pay for the gum graft (41870), dental surgery 
procedure (41899), and office consultation (99242) provided on June 9, 2021.