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

 
We decided that the Plan does not have to pre-approve the removal of lateral exostosis (D7471) to be provided 
by a participating provider. 
 
You asked the Plan to pre-approve the removal of lateral exostosis. You say that if you do not receive D7471 
your denture will never fit over your gums. The Plan denied your request. The Plan says D7471 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 
removal of lateral exostosis (D7471) to be provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction, erupted tooth or exposed root (elevation 
and/or forceps removal) (D7140), limited oral evaluation - problem focused (D0140) and intraoral - periapical 
first radiographic image (D0220) provided December 17, 2021. 
 
You asked the Plan to pay for the tooth extractions, limited oral exam and periapical x-ray. You say that you 
would like these services 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 extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140), limited oral evaluation - 
problem focused (D0140) and intraoral - periapical first radiographic image (D0220) provided December 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay the in network rate for the dental services provided on October 
26, 2021. 
 
You asked the Plan to pay the in network rate for the dental services. You say that the provider in this case is 
listed on the plan's website as in network. The Plan denied your request. The Plan says dental services received 
outside of the plan's dental vendor 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, dental services received outside of the 
plan's dental vendor network are not among those covered under this benefit. Therefore, we decided that the 
Plan does not have to pay the in network rate for the dental services provided on October 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of implant body: endosteal implants 
(D6010), custom fabricated abutments - includes placement (D6057), and abutment supported porcelain fused 
to metal crowns (noble metal) (D6061). 
 
You asked the Plan to pre-approve the endosteal implants, custom fabricated abutments and abutment 
supported crowns. You say that this is an emergency because you are in pain and having difficulty eating. 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 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 
surgical placement of implant body: endosteal implants (D6010), custom fabricated abutments - includes 
placement (D6057), and abutment supported porcelain fused to metal crowns (noble metal) (D6061).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prefabricated abutments  includes modification and 
placement (D6056) and abutment supported porcelain fused to metal crowns (predominantly base metal) 
(D6060). 
 
You asked the Plan to pre-approve prefabricated abutments and abutment supported crowns. You say that 
implants need to be restored with abutments and crowns. 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 pre-approve 
prefabricated abutments  includes modification and placement (D6056) and abutment supported porcelain 
fused to metal crowns (predominantly base metal) (D6060).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power seat elevation system (CPT code E2300) and bag 
hooks (CPT code K0108). 
 
You asked the Plan to pre-approve the items. You say that the items are necessary. The Plan denied your 
request. The Plan says the items are not covered by Medicare or the health plan. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.    
The request for bag hooks it not approved. These items do not serve a medical need and cannot be covered. 
Medicare rules state that "deluxe" or unnecessary upgrades to equipment will not be covered. Furthermore, the 
rules say that a power seat elevation feature (E2300) and power standing feature (E2301) are non-covered 
because they are not primarily medical in nature. If a wheelchair has an electrical connection device described 
by code E2310 or E2311 and if the sole function of the connection is for a power seat elevation or power 
standing feature, it will be denied as non-covered. Therefore, we decided that the Plan does not have to pre-
approve power seat elevation system (CPT code E2300) and bag hooks (CPT code K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the push down handles (K0108). 
 
You asked the Plan to pre-approve the push down handles. You say that you would like reconsideration 
because the requested wheelchair and accessories are medically necessary. The Plan denied your request. The 
Plan says the requested handles do not serve a medical purpose. 
 
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. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve the push down handles (K0108).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gingivectomy/gingivoplasty to be provided by a 
participating provider. 
 
You asked the Plan to pre-approve gingivectomy/gingivoplasty. You say that you would like the Plan to pay 
for this. The Plan denied your request. The Plan says the requested dental benefit is not a covered dental 
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 
gingivectomy/gingivoplasty to be provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal maintenance (D4910). 
 
You asked the Plan to pre-approve the dental service. You say that you were advised you have a problem with 
tartar on your teeth. You also say that you feel this is age discrimination. The Plan denied your request. The 
Plan says the claim was processed correctly. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and periodontal maintenance is listed as 
covered, the frequency limit of twice per 12 months has been reached. The record shows that the Plan paid for 
periodontal maintenance that you received on November 29, 2021 and March 30, 2021. Therefore, we decided 
that the Plan does not have to pre-approve periodontal maintenance (D4910).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150), and an 
extraction (D7210) provided to be provided by an oral surgeon. 
 
You asked the Plan to pre-approve dental services. You say that you were told that these services would be 
covered. The Plan denied your request. The Plan says the dental rules for these services have not been met. 
 
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 does not cover dental 
services when the services are provided by an oral surgeon.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of dental services have not been met. Therefore, we decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150), and an extraction (D7210) provided to be provided by an 
oral surgeon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of an implant body (D6010), 
prefabricated abutment (D6056) and an abutment supported crown (D6060) for tooth #30. 
 
You asked the Plan to pre-approve the implant services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says these services are not covered by your dental benefit. 
 
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 
surgical placement of an implant body (D6010), prefabricated abutment (D6056) and an abutment supported 
crown (D6060) for tooth #30.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the 18 extractions provided on August 12, 2021. 
 
You asked the Plan to reimburse you for the dental services. You say that you paid $8,000 out of pocket. You 
say that you were not reimbursed. You also say that you feel this should be reconsidered. The Plan denied your 
request. The Plan says payment cannot be made to a provider that has opted out of Medicare. 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, dental services performed by a 
provider that has opted out of Medicare are not among those covered under this benefit. Therefore, we decided 
that the Plan does not have to reimburse you for the 18 extractions provided on August 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interim partial upper denture (D5820) and an interim 
partial lower denture (D5821). 
 
You asked the Plan to pre-approve interim dentures. You say that these services are necessary. The Plan denied 
your request. The Plan says these types of dentures are not covered by the Plan's 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 pre-approve an 
interim partial upper denture (D5820) and an interim partial lower denture (D5821).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral exam (D0120) and prophylaxis (D1110) provided on 
October 27, 2021. 
 
You asked the Plan to pay for the dental services. You say that the services that the enrollee received are free. 
The Plan denied your request. The Plan says the annual maximum benefit of $1,000 has 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 and the services are listed as covered, 
the annual maximum benefit of $1,000 has been exhausted. The record shows that the Plan paid $1,000 for 
services that the enrollee received on January 11, 2021. Therefore, we decided that the Plan does not have to 
pay for the oral exam (D0120) and prophylaxis (D1110) provided on October 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic radiographic image (D0330), and a consultation 
(D9310) provided by an out-of-network provider on November 16, 2021. 
 
You asked the Plan to pay for dental services. You say that you would like the Plan to pay for this. You say that 
this was an emergency due to pain. The Plan denied your request. The Plan says the rendered dental 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 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 
panoramic radiographic image (D0330), and a consultation (D9310) provided by an out-of-network provider on 
November 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endosteal implant (D6010 and D011), a bone graft 
(D6104), and a radiographic implant index (D6190) provided by a participating provider. 
 
You asked the Plan to pre-approve dental services. You say that these teeth or needed to chew food properly. 
The Plan denied your request. The Plan says the requested dental services are not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
endosteal implant (D6010 and D011), a bone graft (D6104), and a radiographic implant index (D6190) 
provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the filling (D2331) provided on December 22, 2021. 
 
You asked the Plan to pay for the dental service. You say that you feel this should be covered. The Plan denied 
your request. The Plan says the claim was processed correctly. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and 2 fillings are covered per calendar 
year, the frequency limit has been exceeded. The record shows that the Plan paid for 2 fillings that you received 
on March 3, 2021, and April 19, 2021. Therefore, we decided that the Plan does not have to pay for the filling 
(D2331) provided on December 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement graft (D4263) and guided tissue 
regeneration (D4267) for tooth #6. 
 
You asked the Plan to pre-approve the dental services. You say that these services are necessary. The Plan 
denied your request. The Plan says these services are not covered by the Plan's dental benefit. 
 
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 (D4263) and guided tissue regeneration (D4267) for tooth #6.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implant/abutment supported removable dentures 
(D6110, D6111) and semi-precision abutments (D6191). 
 
You asked the Plan to pre-approve the dental services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says these services are not covered by the Plan's 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 pre-approve 
implant/abutment supported removable dentures (D6110, D6111) and semi-precision abutments (D6191).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of residual tooth roots (D7250 x 2), 
alveoloplasty (D7311), and take home drugs (D9630 x 3). 
 
You asked the Plan to pre-approve removal of residual tooth roots, alveoloplasty, and take home drugs. You 
say that you were advised by a plan representative to get a pre exam for teeth removal. You say that you did 
what you were told. You say that you are now being screwed around about extractions. You also say that you 
have been in discomfort for months and need help. The Plan denied your request. The Plan says the removal of 
residual tooth roots, alveoloplasty, and take home drugs are not listed as covered services. 
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 removal of residual tooth 
roots, alveoloplasty, and take home drugs are not among those covered under this benefit. Therefore, we 
decided that the Plan does not have to pre-approve removal of residual tooth roots (D7250 x 2), alveoloplasty 
(D7311), and take home drugs (D9630 x 3).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical access to an implant body (D6011 x 2), bone 
graft at time of implant placement (D6104 x 2), and guided tissue regeneration (D4266 x 2). 
 
You asked the Plan to pre-approve the dental services. You say that the services are necessary. The Plan denied 
your request. The Plan says the requested dental services are not listed as covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested surgical access to an 
implant body, bone graft at time of implant placement, and guided tissue regeneration are not among those covered under this benefit. Additionally, the services you are asking the Plan to pre-approve involve the care, 
treatment, filling, removal or replacement of the enrollees teeth or the structures directly supporting the 
enrollees teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided 
that the Plan does not have to pre-approve surgical access to an implant body (D6011 x 2), bone graft at time of 
implant placement (D6104 x 2), and guided tissue regeneration (D4266 x 2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral x-ray (D0220), limited oral exam (D0140) and 
periodontal maintenance (D4910) provided on July 22, 2021, and August 23, 2021. 
 
You asked the Plan to pay for the dental services. You say that your provider states that they have not opted out 
of Medicare, and you cannot afford this bill. The Plan denied your request. The Plan says the provider in this 
case does not participate in Original Medicare, and therefore these services are not eligible for payment. 
 
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. Your contract with the Plan 
states that you may see any licensed dental provider who accepts Medicare patients in the United States and has 
not opted out of Original Medicare. If you use a provider that has opted out of Medicare, you will not receive 
reimbursement. Though the Plan offers a dental benefit in excess of Medicare coverage, items or services received from 
providers who have opted out of Original Medicare are not covered under this benefit. The dentist in this case 
is on the Centers for Medicare and Medicaid Services list of providers who have chosen to opt out of Medicare. 
Therefore, we decided that the Plan does not have to pay for the intraoral x-ray (D0220), limited oral exam 
(D0140) and periodontal maintenance (D4910) provided on July 22, 2021, and August 23, 2021.