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

 
We decided that the Plan does not have to pay for the autogenous connective tissue graft procedure (D4273) or 
pay more for the problem focused limited oral evaluation (D0140) provided on July 22, 2021, and August 24, 
2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the autogenous connective tissue graft procedure and to pay more for the 
problem focused limited oral evaluation. You say that you were given insufficient information. The Plan denied 
your request. The Plan says the autogenous connective tissue graft procedure is not a covered expense under 
your dental plan. The problem focused limited oral evaluation was rendered OON, and you are responsible for 
any difference between the Maximum Allowable Fee and the amount the provider bills you for the services. 
The Plan also says that you did not contact the Plan prior to the date of service to verify benefits and provider 
eligibility.  
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the autogenous connective tissue graft 
procedure is not among those covered under this benefit. You are also responsible for the difference between 
the billed amount and allowed amount for covered dental services that are received OON. Therefore, we 
decided that the Plan does not have to pay for the autogenous connective tissue graft procedure (D4273) or pay 
more for the problem focused limited oral evaluation (D0140) provided on July 22, 2021, and August 24, 2021 
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 diagnostic service consultation (D9310) provided by a 
participating provider on March 23, 2022. 
 
You asked the Plan to pay for a diagnostic service consultation. You say that you would like the Plan to pay for 
this. The Plan denied your request. The Plan says D9310 is not a covered dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
diagnostic service consultation (D9310) provided by a participating provider on March 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213) and mandibular 
partial denture (D5214). 
 
You asked the Plan to pre-approve the partial dentures. You say that you would like these dentures to be 
covered because you do not want to pay out of pocket for them. The Plan denied your request. The Plan says 
these services are not covered 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 pre-approve a 
maxillary partial denture (D5213) and mandibular partial denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction of tooth #25 (D7140) provided on April 21, 2022. 
 
You asked the Plan to pay for an extraction. You say that this service is medical necessary due to a pre-existing 
medical condition. The Plan denied your request. The Plan says an extraction (D7140) is not covered by your 
dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 an 
extraction of tooth #25 (D7140) provided on April 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for retainer crowns on tooth #6, 10, and 11 (D6740) and pontics 
on tooth #7, 8, and 9 (D6245) provided on March 29, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told these services were covered. The 
Plan denied your request. The Plan says retainer crowns (D6740) and pontics (D6245) are not covered by your 
supplemental dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for retainer 
crowns on tooth #6, 10, and 11 (D6740) and pontics on tooth #7, 8, and 9 (D6245) provided on March 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a resin-based composite (D2331) and an amalgam 
(D2140), provided by an out-of-network provider on May 3, 2021. 
 
You asked the Plan to pay more for the dental services. You say that this provider was listed as 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. 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 resin-based composite (D2331) and an 
amalgam (D2140), provided by an out-of-network provider on May 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retainer crowns (D6750 x 3), and pontics (D6240 x 2). 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee needs these services. The Plan 
denied your request. The Plan says retainer crowns and pontics 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 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 
retainer crowns (D6750 x 3), and pontics (D6240 x 2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the comprehensive oral evaluation (D0150) and 
complete series of intraoral x-rays (D0210) provided on April 14, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay more for the comprehensive oral evaluation and complete series of intraoral x-rays. 
You say that the dentist did not advise that they were OON. You also say that you would like these charges to 
be paid in full. The Plan denied your request. The Plan says these services were rendered by an OON provider. 
The Plan also says that you are responsible for any charged amount above the Plan's cost-sharing amount when 
your services are received from an OON provider. 
 
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. 
 
You have been asked to pay the difference between the out-of-network provider's charges and the Plan's 
payment. 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 the comprehensive oral evaluation (D0150) 
and complete series of intraoral x-rays (D0210) provided on April 14, 2022 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on November 1, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on November 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of impacted tooth - partially bony (D7230). 
 
You asked the Plan to pre-approve removal of impacted tooth. You say that you feel this service should be 
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 
removal of impacted tooth - partially bony (D7230).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bitewing x-rays (D0274) provided on October 21, 2020. 
 
You asked the Plan to pay for the dental services. You say that you were not informed the provider was out-of-
network. The Plan denied your request. The Plan says the dental services were received from an out-of-network 
provider and are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 bitewing x-rays (D0274) provided on October 21, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure code 45385 billed for date of service September 
22, 2021. 
 
You asked the Plan to pay for procedure code 45385. You say that you have submitted medical records to 
support payment of this code. The Plan denied your request. The Plan says payment for code 45385 is bundled 
into payment for code 45388. 
 
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 45385 
is a column II code to column I code 45388. 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 45385 billed for date of service September 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a custom fabricated abutment (D6057) and an abutment 
supported porcelain/ceramic crown (D6058), provided by an in-network provider on February 23, 2022. 
 
You asked the Plan to pay for a custom fabricated abutment and an abutment supported porcelain/ceramic 
crown. You say that you need this dental work done. The Plan denied your request. The Plan says these 
services have been correctly denied. 
 
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 a custom 
fabricated abutment (D6057) and an abutment supported porcelain/ceramic crown (D6058), provided by an in-
network provider on February 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the special anesthesia service (99100) provided on January 
26, 2022. 
 
You asked the Plan to pay for the special anesthesia service (99100). You say that the completed records 
should be reviewed, and the claim reprocessed for payment. The Plan denied your request. The Plan says 
procedure codes 01925 and 36620 have been overturned. The Plan also says procedure code 99100 remains 
denied as bundled services are not eligible for separate reimbursement. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99100 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the special anesthesia service (99100) have not been met. Therefore, we decided that the Plan does not have 
to pay for the special anesthesia service (99100) provided on January 26, 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 March 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service March 8, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on 
March 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay the in network rate for the additional periapical x-ray (D0230) 
provided on March 10, 2022. 
 
You asked the Plan to pay the in network rate for the additional periapical x-ray. You say that this was an 
emergency. You say that you tried to find an in network dentist. You say that you went to your family doctor 
instead. You also say that by the time you were able to see a dentist you had a severe infection with numbness. 
The Plan denied your request. The Plan says the claim 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 periapical x-ray is listed as 
covered, frequency limitations apply. The record shows that the Plan paid for the initial periapical x-ray that 
you received on the date of service in this case. Therefore, we decided that the Plan does not have to pay the in 
network rate for the additional periapical x-ray (D0230) provided on March 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite (D2331) for tooth #8 provided by an 
out-of-network provider on February 25, 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 the dental services were received from an out-of-network provider and are 
not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 resin-based composite (D2331) for tooth #8 provided by an out-of-network provider on February 
25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the retainer crowns (D6750, D6790), and pontic (D6210) 
provided on February 24, 2022. 
 
You asked the Plan to pay for the dental services. You say that the bridge would be the least invasive, most 
effective and inexpensive solution for your condition. You also say that you would like these services to be 
covered. The Plan denied your request. The Plan says the dental services you received 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the retainer crowns and pontic are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
retainer crowns (D6750, D6790), and pontic (D6210) provided on February 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the deep sedation/general anesthesia - each subsequent 15-
minute increment (D9223) and removal of impacted tooth - partially bony (D7230) provided December 21, 2021. 
 
You asked the Plan to pay for the deep sedation/general anesthesia and removal of impacted tooth. You say that 
you should receive 50% reimbursement as an outpatient surgery. 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 deep sedation/general anesthesia - each subsequent 15-minute increment (D9223) and removal of impacted tooth - 
partially bony (D7230) provided December 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on October 18, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.   
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on October 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the immediate mandibular denture (D5140) and extractions 
(D7140 and D7210) provided on March 23, 2022. 
 
You asked the Plan to pay for the immediate mandibular denture and extractions. You say that you cannot 
afford to pay this amount. The Plan denied your request. The Plan says these services are not covered expenses 
under your dental plan. The Plan also says that you did not contact the Plan prior to this date of service to 
verify benefits and provider eligibility. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 
immediate mandibular denture (D5140) and extractions (D7140 and D7210) provided on March 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve extractions of tooth #11, 12, 13, 15, 19, 20, 21, 22, 23, 
24, 25, 26, 27, 28, 30, and 31 (D2710). 
 
You asked the Plan to pre-approve the dental services. You say that it is medically necessary to have all the 
extractions done at the same time. 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 1, 2022, and April 
15, 2022. Therefore, we decided that the Plan does not have to pre-approve extractions of tooth #11, 12, 13, 15, 
19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 30, and 31 (D2710).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infrared therapy (97026) provided on February 10, 2022. 
 
You asked the Plan to pay for the infrared therapy. You say that the acupuncture codes should be paid. The 
Plan denied your request. The Plan says infrared therapy is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that the use of infrared therapy devices and any 
related accessories is not reasonable and necessary.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the infrared therapy have not been met. Specifically, infrared therapy is not covered by Medicare. 
Therefore, we decided that the Plan does not have to pay for the infrared therapy (97026) provided on February 
10, 2022.