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

 
We decided that the Plan does not have to pay for the full mouth debridement (D4355) provided on May 11, 2022. 
 
You asked the Plan to pay for the full mouth debridement. You say that your dental insurance did not advise 
you on the different kinds of cleanings. You also say that you thought this service was covered. The Plan 
denied your request. The Plan says this procedure is not a benefit under the dental plan. 
 
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 full 
mouth debridement (D4355) provided on May 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone replacement graft (D7953) provided by an out-of-
network provider on February 15, 2022. 
 
You asked the Plan to pay for a bone replacement graft. You say that you would like the Plan to pay for this. 
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 bone 
replacement graft (D7953) provided by an out-of-network provider on February 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the application of fluoride varnish (D1206) provided on 
March 23, 2022. 
 
You asked the Plan to pay for fluoride varnish. You say that this service is under preventive services, and it 
should be covered. The Plan denied your request. The Plan says the application of fluoride varnish (D1206) 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 pay for the 
application of fluoride varnish (D1206) provided on March 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an unspecified preventive procedure (D1999), periapical x-
ray (D0220), a limited oral evaluation (D0140), and resin-based composite filling (D2330) provided on March 
25, 2022. 
 
You asked the Plan to pay for the dental services. You say that the office was listed as in-network. 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 Plan's 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 unspecified preventive procedure (D1999), periapical x-ray (D0220), a limited oral evaluation 
(D0140), and resin-based composite filling (D2330) provided on March 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and 
first intraoral periapical x-ray (D0220) provided on March 21, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the problem focused limited oral evaluation and first intraoral periapical x-ray. 
You say that you received an authorization prior to receiving these services. You also say that the authorization 
was processed according to your medical benefit, not dental. The Plan denied your request. The Plan says 
services performed by an OON provider are not covered because your healthcare plan does not have OON 
benefits. Although you received an authorization to be treated by this OON provider, the service code 
authorized was an outpatient office visit (99214) under your medical coverage. The Plan also says the services 
being appealed were billed to your dental coverage, which the authorization is not based on. 
 
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, you are responsible for 100% of the 
cost for dental services rendered by an OON provider. Therefore, we decided that the Plan does not have to pay 
for the problem focused limited oral evaluation (D0140) and first intraoral periapical x-ray (D0220) provided 
on March 21, 2022 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite filling on tooth #27 (D2332) 
provided on November 10, 2021. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says your benefit for the requested 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 June 3, 2021, and 
November 10, 2021. Therefore, we decided that the Plan does not have to pay for a resin-based composite 
filling on tooth #27 (D2332) provided on November 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive periodontal evaluation (D0180) provided 
on March 24, 2022. 
 
You asked the Plan to pay for an evaluation. You say that there should be a $0 copayment for all 
comprehensive dental services. The Plan denied your request. The Plan says a comprehensive periodontal 
evaluation (D0180) 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 pay for a 
comprehensive periodontal evaluation (D0180) provided on March 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core build up (D2950), localized delivery of antimicrobial 
agents (D4381), periodontal scaling and root planing (D4342, D4341), gingival irrigation (D4921), and drugs 
dispensed in the office (D9630) provided on April 13, 2022, and crowns (D2740) provided on April 27, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says these dental services are not covered by your supplemental 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 core build 
up (D2950), localized delivery of antimicrobial agents (D4381), periodontal scaling and root planing (D4342, 
D4341), gingival irrigation (D4921), and drugs dispensed in the office (D9630) provided on April 13, 2022, 
and crowns (D2740) provided on April 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cone beam imaging (D0364) provided on March 31, 2022. 
 
You asked the Plan to pay for imaging. You say that you disagree with the denial of dental services. The Plan 
denied your request. The Plan says cone beam imaging (D0364) is not covered by your supplemental 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 cone 
beam imaging (D0364) provided on March 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pulpal debridement on tooth #31 (D3221) provided on March 
23, 2022. 
 
You asked the Plan to pay for debridement. You say that the services were an emergency. The Plan denied your 
request. The Plan says pulpal debridement (D3221) is not covered by your supplemental dental 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 pulpal 
debridement on tooth #31 (D3221) provided on March 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83789 billed for date of service February 12, 2022. 
 You asked the Plan to pay for procedure code 83789. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 83789 is bundled into payment for code G0481. 
 
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 83789 
is a column II code to column I code G0481. This claim has not been billed with an appropriate modifier to 
bypass the edit. The -59 modifier is not supported as a separate and distinct procedural service. 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 83789 billed for date of service February 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), first intraoral periapical 
x-ray (D0220), bitewing x-rays (D0277), and prophylaxis (D1110) provided on March 22, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the dental services. You say that you were seeing this dentist prior to switching 
to this insurance plan. 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 Plan's 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 the periodic oral evaluation (D0120), first intraoral periapical x-ray (D0220), bitewing x-rays 
(D0277), and prophylaxis (D1110) provided on March 22, 2022 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate. 
 
You asked the Plan to pre-approve bone marrow aspirate. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the denial of authorization for this service is correct, 
because studies have not shown that bone marrow aspirate is helpful for treatment of the enrollee's condition. 
 
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 bone marrow aspirate. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found bone marrow aspirate remains experimental, more research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the autograft rendered on December 12, 2021, to December 
15, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 20936 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 20936 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of these services have not been met. Therefore, we decided that the Plan does not have to pay for the autograft 
rendered on December 12, 2021, to December 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and bitewing x-
rays (D0274) provided on January 24, 2022.
 
You asked the Plan to pay for the dental services. You say that the provider missed your infected tooth and you 
needed to see a different provider for an evaluation. The Plan denied your request. The Plan says your benefit 
for the requested items or services has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the Plan paid for the requested items or services for date of service January 25, 2022; therefore, the benefit for a comprehensive oral evaluation and bitewing x-rays has been exhausted. We decided that the Plan 
does not have to pay for a comprehensive oral evaluation (D0150) and bitewing x-rays (D0274) provided on 
January 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for the partial lower denture (D5214) 
provided on March 28, 2022. 
 
You asked the Plan to pay an additional amount for the dental item. You say that you need dentures. You also 
say that you cannot afford to pay this amount. The Plan denied your request. The Plan says that the calendar 
year maximum has been exhausted in the processing of this claim. 
 
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, there is a calendar year maximum that 
applies. The record shows that that Plan paid $905 for services you received on the date of service in this case, 
and $95 for services received on March 1, 2022. $905 + $95 = $1,000. 
 
Therefore, we decided that the Plan does not have to pay an additional amount for the partial lower denture 
(D5214) provided on March 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete series of intraoral x-rays (D0210) provided on 
March 24, 2022. 
 
You asked the Plan to pay for the complete series of intraoral x-rays. You say that you asked the provider if 
they accepted your insurance, and they said yes. 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 Plan's 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 January 29, 2018.  
 
Therefore, we decided that the Plan does not have to pay for the complete series of intraoral x-rays (D0210) 
provided on March 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220) and additional 
intraoral periapical x-ray (D0230) provided on November 30, 2021. 
 
You asked the Plan to pay for the intraoral periapical x-rays. You say that you should not have to pay $86.00 
for these services. The Plan denied your request. The Plan says these services are not covered expenses under 
your dental plan. The Plan also says that you did not contact the Plan prior to the date of service to verify 
benefits and provider eligibility. 
 
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 first intraoral periapical x-ray (D0220) and 
additional intraoral periapical x-ray (D0230) provided on November 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown lengthening procedure on tooth #3 and 13 
(D4249). 
 
You asked the Plan to pre-approve crown lengthening procedure. You say that this service should be covered. 
The Plan denied your request. The Plan says a crown lengthening procedure (D4249) 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 a 
crown lengthening procedure on tooth #3 and 13 (D4249).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and periapical x-ray 
(D0220) provided on March 24, 2022, by the out of network provider. 
 
You asked the Plan to pay for the dental services. You say that when you searched for a dentist this was the 
only office that came up. The Plan denied your request. The Plan says dental services received out of network 
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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and the dental services are listed as 
covered, they are not among those covered under this benefit when received out of network. Therefore, we 
decided that the Plan does not have to pay for the limited oral evaluation (D0140) and periapical x-ray (D0220) 
provided on March 24, 2022, by the out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the first intraoral periapical image (code D0220) and 
intraoral - periapical each additional film (code D0230) provided on March 17, 2022. 
 
You asked the Plan to pay for the dental services. You say that you thought the services were part of the routine 
dental care. The Plan denied your request. The Plan says the service provided is not a covered benefit under 
your dental plan. The Plan says you are not enrolled in the Supplemental which offers additional 
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 the first 
intraoral periapical image (code D0220) and intraoral - periapical each additional film (code D0230) provided 
on March 17, 2022.