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

 
We decided that the Plan does not have to pay for the cone beam computed tomography (CT) scan (D0360), 
three surgical placements of implant bodies: endosteal implants (D6010 x3), two bone replacement grafts for 
ridge preservation (D7953 x2), and intravenous moderate (conscious) sedation/analgesia services (D9241 and 
D9242) provided form February 16, 2022, to April 25, 2022. 
 
You asked the Plan to pay for the cone beam CT scan, endosteal implants, bone replacement grafts, and 
sedation/analgesia services. You say that you would like these services to be approved for payment. The Plan 
denied your request. The Plan says these 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 cone beam CT scan and bone 
replacement grafts are not among those covered under this benefit. The contract says that dental implants are 
covered to hold a complete denture. There was no information provided showing these implants were provided 
to hold a complete denture. The Plan contract also says that prior authorization is needed for intravenous 
sedation services. The provided documentation does not include an authorization request for the intravenous 
moderate (conscious) sedation/analgesia services that were rendered. Therefore, we decided that the Plan does 
not have to pay for the cone beam computed tomography (CT) scan (D0360), three surgical placements of 
implant bodies: endosteal implants (D6010 x3), two bone replacement grafts for ridge preservation (D7953 x2), 
and intravenous moderate (conscious) sedation/analgesia services (D9241 and D9242) provided form February 
16, 2022, to April 25, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve crowns on tooth #7 and 8 (D2752). 
 
You asked the Plan to pre-approve crowns. You say that the crowns are medically necessary. The Plan denied 
your request. The Plan says that the requested services are only covered when received by an in-network 
provider. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not provide a complete copy of the Evidence of Coverage (EOC). 
Without the complete EOC we are unable to determine if the prior authorization was processed correctly. 
Therefore, we decided that the Plan has to pre-approve crowns on tooth #7 and 8 (D2752).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the root canal (D3330) for tooth #31 provided on May 
7, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you were told the provider was in-network 
and you would like the claim to be paid. 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 dental services maximum benefit was exhausted on date of service of May 7, 2022. Therefore, we 
decided that the Plan does not have to pay more for the root canal (D3330) for tooth #31 provided on May 7, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an irrigation of gingival pockets with medicinal agent on 
July 15, 2022. 
 
You asked the Plan to pay for an irrigation of gingival pockets with medicinal agent. You say that you would 
like to request reconsideration of the denied claim. The Plan denied your request. The Plan says the service is 
not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an 
irrigation of gingival pockets with medicinal agent on July 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral periapical x-ray (D0220), 2D oral/facial imaging 
(D0350), removal of plaque (D1110) and alveolus closed reduction (D7670) provided on April 11, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says these services are not covered by Medicare or the Plan. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
 
  The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for the intraoral periapical x-ray 
(D0220), 2D oral/facial imaging (D0350), removal of plaque (D1110) and alveolus closed reduction (D7670) 
provided on April 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oral evaluation (D0140), and x-rays (D0220 and D0230) 
for tooth #12 and #15 provided on June 30, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for the dental 
services. The Plan denied your request. The Plan says the denial of payment for these services is correct, 
because an oral evaluation and the x-rays 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 pay for an oral 
evaluation (D0140), and x-rays (D0220 and D0230) for tooth #12 and #15 provided on June 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental cutting (D7250) provided on May 11, 2022. 
 
You asked the Plan to pay for the dental cutting. 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 dental 
cutting (D7250) provided on May 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and a complete 
series of intraoral x-rays (D0210) provided on June 20, 2022. 
 
You asked the Plan to pay for the dental services. You say that you wanted to get your dental issues looked at 
before it got worse. 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 items or services were exhausted on date of service May 26, 2021. 
Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and a 
complete series of intraoral x-rays (D0210) provided on June 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for sedation services (99153) provided on January 21, 2022. 
 
You asked the Plan to pay for sedation services. You say that this is supported in the records. The Plan denied 
your request. The Plan says this cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that payment is not made under the physician fee 
schedule for Technical Component (TC) services furnished in institutional settings where the TC service is bundled into the facility payment, e.g., hospital inpatient and outpatient settings. The rules also say that a 
Professional Component (PC)/Technical Component (TC) Indicator of 3 denotes technical component only 
codes. 
 
We looked at the file and Medicare rules. Code 99153 has a PC/TC indicator of 3 and was billed in an inpatient 
setting. Based on this information, we decided that Medicare rules for coverage of sedation services have not 
been met. Therefore, we decided that the Plan does not have to pay for sedation services (99153) provided on 
January 21, 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 June 2, 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 January 25, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on 
June 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for panoramic radiographic image (D0330) and reline complete 
maxillary denture (laboratory) (D5750) provided on May 24, 2022. 
 
You asked the Plan to pay for dental services. You say that you would like these services covered. 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. Panoramic radiographic image 
and reline complete maxillary denture (laboratory) are not covered under the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested panoramic radiographic 
image (D0330) and reline complete maxillary denture (laboratory) (D5750) are not among those covered under 
this benefit. Therefore, we decided that the Plan does not have to pay for panoramic radiographic image 
(D0330) and reline complete maxillary denture (laboratory) (D5750) provided on May 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for endodontic therapy of molar tooth #3 (D3330) provided on 
May 12, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the dental services. You say that the services were emergent in nature. You also 
say that without receiving the services, your medical condition would have progressed into a medical 
emergency The Plan denied your request. The Plan says the services were rendered by an out-of-network 
provider and the Plan does not cover services provided by out-of-network providers.  
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 
 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for endodontic therapy of molar tooth #3 (D3330) 
provided on May 12, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gingival irrigation (D4921) provided by a participating 
provider. 
 
You asked the Plan to pre-approve gingival irrigation. You say that these services are medically necessary. The 
Plan denied your request. The Plan says the requested 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 pre-approve 
gingival irrigation (D4921) provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a surgical extraction (D7210) and placement of an intra-
socket biological dressing (D7922) provided on March 1, 2022. 
 
You asked the Plan to pay for the dental services. You say that you do not understand why the Plan covers out-
of-network simple extractions with a 50 percent coinsurance but does not cover surgical extractions. The Plan 
denied your request. The Plan says the services are not listed as covered under your dental benefits. This means 
the services are exclusions and cannot be paid. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 
 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a surgical 
extraction (D7210) and placement of an intra-socket biological dressing (D7922) provided on March 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93319 billed for date of service May 27, 
2022. 
 
You asked the Plan to pay for procedure code 93319. You say that you have provided records to support the 
code billed. The Plan denied your request. The Plan says rules for payment have not been met because the code 
at issue is included in another billed code. 
 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 93319 
is a column II code to column I code 93325 with a modifier indicator of 0. The column II code is therefore not 
payable. 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 93319 billed for date of service May 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a periodic oral evaluation (D0120), prophylaxis 
(D1110), and bitewing x-rays (D0274) provided on March 22, 2022, and resin-based composite fillings 
(D2391, D2393) provided on April 19, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you were told that the provider was in-
network. The Plan denied your request. The Plan says you are responsible for any charged amount above the 
Plans cost-sharing amount when your services are received from an 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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment.  
 
Date of Service Code Billed Amount Plan Paid Enrollees Share 
March 22, 2022 D0272 $51 $21.63 $29.37 
March 22, 2022 D0120 $47 $24.11 $22.89 March 22, 2022 D1110 $92 $65.40 $26.60 
Claim Total  $78.86 
April 19, 2022 D2393 $284 $41.91 $242.09 
April 19, 2022 D2391 $191 $65.65 $125.35 
Claim Total    $367.44 
 
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 more for a periodic oral evaluation (D0120), prophylaxis (D1110), 
and bitewing x-rays (D0274) provided on March 22, 2022, and resin-based composite fillings (D2391, D2393) 
provided on April 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on December 27, 2021. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the 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 the dental 
services on December 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown restoration supported by an abutment on tooth #19 
(D6060) provided on June 6, 2022. 
 
You asked the Plan to pay for the dental services. You say that during the pre-approval process, you received 
documentation from the Plan that led you to believe this service would be covered. You say that as long as an 
x-ray is taken at least 12 weeks after surgery demonstrating that the implant is successfully healed, the service 
would be covered. The Plan denied your request. The Plan says the claim was processed correctly. The dental 
code, D6060, is not listed as 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 pay for a crown 
restoration supported by an abutment on tooth #19 (D6060) provided on June 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the periodic oral exam (D0120), prophylaxis 
(D1110), and fluoride treatment (D1208) provided on June 2, 2022. 
 
You asked the Plan to waive the cost share for the dental services. You say that you were not told benefits are 
50% of what the Plan deems an appropriate fee for services. 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 50% 
coinsurance when out-of-network for these services.  
 
You have been asked to pay a 50% coinsurance for the out-of-network dental services for a total of $66.50. 
This item/service falls within the Dental Services benefit category. This means that you have been asked to pay 
the correct amount based on your contract with the Plan. 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 waive the 
cost share for the periodic oral exam (D0120), prophylaxis (D1110), and fluoride treatment (D1208) provided 
on June 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the scaling and root planning (D4341) 
 
You asked the Plan to pre-approve the dental services. You say that you never received the dental service 
before. 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 March 21, 2022. 
Therefore, we decided that the Plan does not have to pre-approve the scaling and root planning (D4341)
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the crown (D2740). 
 
You asked the Plan to pre-approve the dental services. You say that you need the crown three months before 
the five-year time frame expires. You say you have a cavity in your crown. 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 October 18, 2018. 
Therefore, we decided that the Plan does not have to pre-approve the crown (D2740).