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

 
We decided that the Plan does not have to pre-approve dentures (D5120) 
 
You asked the Plan to pre-approve the dentures. 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 pre-approve 
dentures (D5120)
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral exam (D0150) and a complete series of 
intraoral x-rays (D0210) provided on March 25, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told by the provider that the office 
accepted your insurance prior to receiving services. 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. 
The Plan also says that neither you nor the provider contacted the Plan prior to the date of service to check 
benefits or network status. No prior authorization was requested for care with this out-of-network provider. 
 
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 a comprehensive oral exam (D0150) and a complete series of intraoral x-rays (D0210) provided on 
March 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an occlusal guard (D9944) 
 
You asked the Plan to pre-approve the occlusal guard. 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 pre-approve an 
occlusal guard (D9944)
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740) and core buildup (D2950) for tooth #21 
provided on June 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that you should have never received a bill for these 
services, and they should be covered. The Plan denied your request. The Plan says your benefit for all dental 
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 Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. On April 6, 
2022, the Plan paid $2,673.86 for dental services. On April 21, 2022, the Plan paid $656 for dental services. On 
April 18, 2022, the Plan paid $670.14 for dental services. The total amount the Plan paid for the yearly dental 
benefits was $4,000 ($2,673.86 total + $656 total + $670.14); therefore, the record shows your dental benefit 
for the year was exhausted on date of service April 18, 2022. Therefore, we decided that the Plan does not have 
to pay for a crown (D2740) and core buildup (D2950) for tooth #21 provided on June 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for complete denture - maxillary (D5110) and complete denture 
- mandibular (D5120) provided on May 6, 2022. 
 
You asked the Plan to pay for the dental services. You say that you need the requested 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. Complete denture - maxillary 
(D5110) and complete denture - mandibular (D5120) are covered benefits but have a limit of one every five 
plan years. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested complete denture - maxillary (D5110) and complete denture - mandibular 
(D5120) was exhausted on date of service December 9, 2019. Therefore, we decided that the Plan does not 
have to pay for complete denture - maxillary (D5110) and complete denture - mandibular (D5120) provided on 
May 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of torus palatinus (D7472). 
 
You asked the Plan to pre-approve the removal of torus palatinus (D7472). You say that the roof of your mouth 
drops down making it impossible to wear an upper denture. You also say that this is not a cosmetic procedure 
but a necessity to improve your health and overall well-being. The Plan denied your request. The Plan says the 
requested service is not covered by Medicare or 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. The Plan rules say that these 
services are not covered. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
removal of torus palatinus (D7472).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation and panoramic x-ray 
(D0150, D0330) provided on May 3, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. 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 February 05, 2020. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation and panoramic x-
ray (D0150, D0330) provided on May 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided by a 
participating provider on April 20, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for these 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, 2022. The Plan 
processes claims as they are received - the claim for the date of service June 3, 2022, was processed prior to the 
claim for date of service April 20, 2022. Therefore, we decided that the Plan does not have to pay for a 
comprehensive oral evaluation (D0150) provided by a participating provider on April 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the simple extraction (D7140), surgical extraction 
(D7210), and two tooth additions to an existing partial denture (D5650 x2) provided on May 17, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay more for the extractions and tooth additions to an existing partial denture. You say 
that you have been going to this provider for two years and your past claims have been paid. The Plan denied 
your request. The Plan says these services were rendered by an OON provider. The Plan also says that this 
claim has been processed in accordance with your plan 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, you are responsible for a 50% 
coinsurance for each of these services because they were rendered by an OON provider. Therefore, we decided 
that the Plan does not have to pay more for the simple extraction (D7140), surgical extraction (D7210), and two 
tooth additions to an existing partial denture (D5650 x2) provided on May 17, 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 dental crown (D2790) provided on April 12, 2022. 
 
You asked the Plan to pay for the dental crown. 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 dental 
crown (D2790) provided on April 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral imaging (D0220 and D0230) provided by a 
participating provider on August 4, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. 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 January 10, 2022. 
Therefore, we decided that the Plan does not have to pay for intraoral imaging (D0220 and D0230) provided by 
a participating provider on August 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oral evaluation - problem focused (D0140) provided on June 
22, 2022. 
 
You asked the Plan to pay for the dental services. You say that you had to find a new provider to perform the 
root canal because your previous provider no longer does root canals. Therefore, you feel you should not have 
to pay for this. 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. Plan covers oral evaluation - 
problem focused (D0140) but is limited to one procedure per plan year. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested oral evaluation - problem focused (D0140) was exhausted on date of 
service March 15, 2022. Therefore, we decided that the Plan does not have to pay for oral evaluation - problem 
focused (D0140) provided on June 22, 2022.
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 denture. You say that you would like the denture covered. The Plan 
denied your request. The Plan says the requested item is not a covered benefit under any circumstances. 
 
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 
complete upper denture (D5110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two-dimensional (2D) oral/facial photographic images 
(D0350) and adjunctive pre-diagnostic test (D0431) provided on July 6, 2022. 
 
You asked the Plan to pay for the 2D oral/facial photographic images and adjunctive pre-diagnostic test. You 
say that you feel you should not be held responsible for these charges. The Plan denied your request. The Plan 
says these services are not covered benefits under your dental 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 two-
dimensional (2D) oral/facial photographic images (D0350) and adjunctive pre-diagnostic test (D0431) provided 
on July 6, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 45831 billed for date of service May 28, 
2022. 
 You asked the Plan to pay for procedure code 45831. You say that this service is supported in the medical 
record. The Plan denied your request. The Plan says payment for code 45831 is bundled into payment for code 
45832. 
 
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 45831 
is a column II code to column I code 45832. This claim has not been billed with an appropriate modifier to 
bypass the edit. 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 45831 billed for date of service May 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve coping on tooth #3, 29, and 30 (D2975) and the 
localized delivery of antimicrobial agents on tooth #5 and 15 (D4381). 
 
You asked the Plan to pre-approve coping and delivery of antimicrobial agents. You say that you disagree with 
the denial of dental services. The Plan denied your request. The Plan says coping (D2975) and the localized 
delivery of antimicrobial agents (D4381) are not covered by the enrollee's dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
coping on tooth #3, 29, and 30 (D2975) and the localized delivery of antimicrobial agents on tooth #5 and 15 
(D4381).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve plate replacing some lower teeth - partial denture 
(D5214). 
 
You asked the Plan to pre-approve the dental services. You say that your denture no longer fits properly, so you 
would like to receive another one. 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. Plate replacing some lower 
teeth - partial denture (D5214) but is limited to one every five years. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested plate replacing some lower teeth - partial denture (D5214) was exhausted 
on date of service December 19, 2020. Therefore, we decided that the Plan does not have to pre-approve plate 
replacing some lower teeth - partial denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical procedure for isolation of tooth with rubber 
dam (D3910) Tooth #14. 
 
You asked the Plan to pre-approve dental services. You say that you would like the requested service approved. 
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. Surgical procedure for 
isolation of tooth with rubber dam (D3910) is not covered under the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested surgical procedure for 
isolation of tooth with rubber dam (D3910) Tooth #14 is not among those covered under this benefit. 
Therefore, we decided that the Plan does not have to pre-approve surgical procedure for isolation of tooth with 
rubber dam (D3910) Tooth #14.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the implant placements (D6010) and custom abutments 
(D6057) for tooth #3, #6, #11, #14, #20, #22, #27, and #29. 
 
You asked the Plan to pre-approve the dental services. You say that you need these dental services done before 
you get your dentures. The Plan denied your request. The Plan says the denial of authorization for these 
services is correct, because dental implants and all associated services 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 
implant placements (D6010) and custom abutments (D6057) for tooth #3, #6, #11, #14, #20, #22, #27, and #29.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on  July 18, 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 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 5, 2021. Therefore, 
we decided that the Plan does not have to pay for the dental services on  July 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and intraoral 
radiographic images (D0210) provided. 
 
You asked the Plan to pay for the dental 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 a 
comprehensive oral evaluation (D0150) and intraoral radiographic images (D0210) provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup (D2950) for tooth #22 provided on July 8, 2022. 
 
You asked the Plan to pay for the dental service. You say that this dental procedure was necessary, and you 
would like it to be covered. The Plan denied your request. The Plan says the denial of payment for this service 
is correct, because core buildup 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 core 
buildup (D2950) for tooth #22 provided on July 8, 2022.