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

 
We decided that the Plan does not have to pay for the resin-based composite - four or more surfaces or 
involving incisal angle (anterior) (D2335) provided on January 31, 2022. 
 
You asked the Plan to pay for the filling. You say that this service is covered under your benefits. 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 resin-
based composite - four or more surfaces or involving incisal angle (anterior) (D2335) provided on January 31, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for resin-based composite  four or more surfaces (D2335)  
50% coinsurance and extraction, erupted tooth requiring removal of bone (D7210)  50% coinsurance provided 
on June 24, 2022, to July 7, 2022. 
 
You asked the Plan to pay for dental services. You say that you would like the Plan to cover the cost of the 
services because the provider is in-network. The Plan denied your request. The Plan says going forward any 
services completed by the provider will be billed as out-of-network. 
 
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 resin-based composite  
four or more surfaces (D2335) and extraction, erupted tooth requiring removal of bone (D7210) are covered 
with a 50% coinsurance under this benefit. This cost sharing is a contractual obligation you agreed to pay when 
you enrolled in the Plan. Therefore, we decided that the Plan does not have to pay for resin-based composite  
four or more surfaces (D2335) and extraction, erupted tooth requiring removal of bone (D7210) provided on 
June 24, 2022, to July 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown - porcelain/ceramic (D2740), and crown - 
porcelain/ceramic (D2954). 
 
You asked the Plan to pre-approve the crown - porcelain/ceramic (D2740), and crown - porcelain/ceramic 
(D2954). You say that the enrollee's dental is at risk. The Plan denied your request. The Plan says we cannot 
determine from the medical records if the services requested are medically necessary; a crown - 
porcelain/ceramic (D2740), and crown - porcelain/ceramic (D2954). 
 
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 crown - 
porcelain/ceramic (D2740), and crown - porcelain/ceramic (D2954) 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 crown - porcelain/ceramic (D2740), 
and crown - porcelain/ceramic (D2954). Our reviewer says that upon review it was determined that the 
documentation provided was inadequate. Our physician reviewer found the radiographs provided were not of 
diagnostic quality. Therefore, a determination of the need for these services could not be made. 
 
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 crown - porcelain/ceramic (D2740), and crown - porcelain/ceramic (D2954) 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a crown - 
porcelain/ceramic (D2740), and crown - porcelain/ceramic (D2954).
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 denied due to your tooth 
has to have a lot of tooth missing from a cavity or have a lot of damage from being broken and it can no longer 
be fixed with a filling. 
 
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 dental 
services when the services are medically necessary and reasonable.  
 
Based on this information, we decided that the Plan's rules for coverage of the dental services have not been 
met. 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 (D2740), provisional crown (D2799), core 
buildup (D2950), endodontic therapy (D3310), a surgical procedure (D3310), other drugs (D9630), and 
application of medicament (D9910) for tooth #5, #6, #7, #8, #9, #10, #11, and #12. 
  You asked the Plan to pre-approve the dental services. You say that you do not know why the Plan is denying 
the dental services and would like the Plan to approve the dental services. The Plan denied your request. The 
Plan says your benefit for the crowns and endodontic therapy has already been exhausted.  Provisional crowns, 
core buildup, surgical procedures, other drugs, and application of medicament 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, certain limitations apply. The record 
shows your benefit for the crowns (D2740) and the endodontic therapy (D3310) was exhausted on the pre-
approval date of August 19, 2022. Also the provisional crowns, core buildup, surgical procedures, other drugs, 
and application of medicament are not covered under the Plans dental benefit. Therefore, we decided that the 
Plan does not have to pre-approve a crown (D2740), provisional crown (D2799), core buildup (D2950), 
endodontic therapy (D3310), a surgical procedure (D3310), other drugs (D9630), and application of 
medicament (D9910) for tooth #5, #6, #7, #8, #9, #10, #11, and #12.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
April 27, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service April 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible intraoral complete series (D0210) provided on 
May 9, 2022. 
 
You asked the Plan to waive the deductible intraoral complete series (D0210). You say that you were told that 
service for cleaning was covered. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $100 deductible which applies to dental services.  
 
 
  You have been asked to pay $98 toward your deductible. The intraoral complete series (D0210) falls within the 
Dental Services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract 
that there is a $100 deductible which applies to dental services. This cost sharing is a contractual obligation that 
had not been met at the time intraoral complete series (D0210) was received on May 9, 2022. Therefore, we 
decided that the Plan does not have to waive the deductible intraoral complete series (D0210) provided on May 
9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on August 8, 
2022. 
 
You asked the Plan to pay for the limited oral evaluation. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they do 
not fall within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a limited 
oral evaluation (D0140) provided on August 8, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral complete series set of x-rays (D0210) provided 
August 4, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were forced to leave your previous dental 
practice because they did not accept the Plan. On your first visit, you were told that your full x-rays of teeth 
were due to be updated. You saw no reason as a first-time patient to question the doctor. The Plan denied your 
request. The Plan says this service is not covered under the Plan 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 complete series set of x-rays (D0210) provided August 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation - problem focused (D0140) 
provided on May 20, 2022, and a comprehensive oral evaluation - new or established patient (D0150), and 
intraoral - complete series of radiographic images (D0210) provided on May 16, 2022. 
 
You asked the Plan to pay for the 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 limited oral evaluation - problem focused (D0140) was exhausted on date of service 
April 26, 2022. The comprehensive oral evaluation - new or established patient (D0150), and intraoral - 
complete series of radiographic images (D0210) was exhausted on the date of service April 14, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation - problem focused 
(D0140) provided on May 20, 2022, and a comprehensive oral evaluation - new or established patient (D0150), 
and intraoral - complete series of radiographic images (D0210) provided on May 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for denture adjustment services (D5750, D5751) provided on 
December 16, 2021. 
 
You asked the Plan to pay for the denture adjustment services. 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 denture 
adjustment services (D5750, D5751) provided on December 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110). 
 
You asked the Plan to pre-approve the dental services. You say that you lost your upper denture, and you need 
a replacement. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on the date of service of December 10, 
2019. Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve metal and tooth colored crown (D2751) tooth #5. 
 
You asked the Plan to pre-approve dental services. You say that this service is needed. The Plan denied your 
request. The Plan says this service is not covered under your Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. Metal and tooth colored crown 
(D2751) is not covered under the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested metal and tooth colored 
crown (D2751) tooth #5 is not among those covered under this benefit. Therefore, we decided that the Plan 
does not have to pre-approve metal and tooth colored crown (D2751) tooth #5.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
May 16, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service May 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 92604 billed for date of service July 19, 
2022.  
You asked the Plan to pay for procedure code 92604. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 92604 is 1. The MAI value for this code is 2. You billed 2 units of 92604-
RT 92604-LT each, exceeding the MUE. Based on this information, we decided that Medicare rules for 
coverage of procedure code 92604 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 92604 billed for date of service July 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve deep sedation/general anesthesia - first 15 minutes 
(D9222) and deep sedation/general anesthesia - each subsequent 15-minute increment (D9223). 
 
You asked the Plan to pre-approve dental services. You say that the provider would prefer to do the dental 
procedure under sedation. The Plan denied your request. The Plan says this service is not covered under your 
Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. Deep sedation/general 
anesthesia - first 15 minutes (D9222) and deep sedation/general anesthesia - each subsequent 15-minute 
increment (D9223) are not covered under the Plans dental benefits.  
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested deep sedation/general 
anesthesia - first 15 minutes (D9222) and deep sedation/general anesthesia - each subsequent 15-minute 
increment (D9223) are not among those covered under this benefit. Therefore, we decided that the Plan does 
not have to pre-approve deep sedation/general anesthesia - first 15 minutes (D9222) and deep sedation/general 
anesthesia - each subsequent 15-minute increment (D9223).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the topical application of fluoride varnish (D1206) provided 
on July 14, 2022. 
 
You asked the Plan to pay for this dental service. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says this service 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 Plans 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 topical 
application of fluoride varnish (D1206) provided on July 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gingivectomy or gingivoplasty to allow access for 
restorative procedure (D4212) and gingival irrigation (D4921). 
 
You asked the Plan to pre-approve gingivectomy or gingivoplasty and gingival irrigation. You say that you 
need these 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 pre-approve 
gingivectomy or gingivoplasty to allow access for restorative procedure (D4212) and gingival irrigation 
(D4921).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 20930 billed for date of service June 5, 2022. 
  You asked the Plan to pay for procedure code 20930. You say that the documentation supports the services 
rendered. The Plan denied your request. The Plan says procedure code 20930 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 20930 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 20930 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 20930 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 20930 billed for date of service June 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the soft tissue grafting (D4277 and D4278) provided on 
March 18, 2022. 
 
You asked the Plan to pay for the dental services. You say that these dental services should be covered under 
the comprehensive services and the Plan should cover the cost. The Plan denied your request. The Plan says the 
denial of authorization for these services is correct, because the soft tissue grafting is 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 pay for the soft 
tissue grafting (D4277 and D4278) provided on March 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of implant body: endosteal implant 
(D6010) for tooth 30. 
 
You asked the Plan to pre-approve an endosteal implant. You say that you need this service covered. 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 pre-approve 
surgical placement of implant body: endosteal implant (D6010) for tooth 30.