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

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and the intraoral-
complete series of radiographic images (D0210) provided on April 6, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says you have exhausted the allowable 
benefit for the services provided in this case. 
 
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 services provided in this case was exhausted on date of service October 27, 2021. 
The Plan contract states that a dental exam is covered once every three calendar years. Additionally, a full 
mouth or panoramic x-ray is covered once every five calendar years. These services were provided to you 
previously on October 27, 2021 and were paid for by the Plan.  Therefore, we decided that the Plan does not 
have to pay for the comprehensive oral evaluation (D0150) and the intraoral-complete series of radiographic 
images (D0210) provided on April 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone graft at time of implant placement (D6104) and 
guided tissue regeneration - nonresorbable barrier, per site (includes membrane removal) (D4267). 
 
You asked the Plan to pre-approve bone graft and guided tissue regeneration. You say that the enrollee needs 
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 bone 
graft at time of implant placement (D6104) and guided tissue regeneration - nonresorbable barrier, per site 
(includes membrane removal) (D4267).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental cleaning (D1110), periodic oral evaluation 
(D0120), intraoral-periapical first radiographic image (D0220), and the intraoral-periapical each additional 
radiographic image (D0230 x 3) provided on January 25, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. 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 Plan's coverage rules apply in this case. 
 
The record shows that you received the dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the services provided 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 
the dental cleaning (D1110), periodic oral evaluation (D0120), intraoral-periapical first radiographic image 
(D0220), and the intraoral-periapical each additional radiographic image (D0230 x 3) provided on January 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the power seat elevation system (CPT code E2300). 
 
You asked the Plan to pre-approve the power seat elevation system. You say that you are unable to get up from 
a standard seat and you need an elevated seat to be able to get up out of the chair. The Plan denied your request. 
The Plan says Medicare does not consider this feature to be primarily medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.    
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve the power seat elevation system (CPT code E2300).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for local anesthesia (D9210) provided by a participating 
provider on March 9, 2022. 
 
You asked the Plan to pay for local anesthesia. You say that you had an infected tooth, and this was the more 
affordable treatment. The Plan denied your request. The Plan says D9120 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 local 
anesthesia (D9210) provided by a participating provider on March 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the maxillary partial denture (D5213) provided on December 
21, 2020. 
 
You asked the Plan to pay for the maxillary partial denture. You say that you would like the Plan to get your 
money back from this dentist who made you a horrific partial denture. You also say that you cannot pay for 
another partial denture. The Plan denied your request. The Plan says this claim processed and paid at the in-
network benefit $303.30 to the provider, and you are responsible for a $707.70 coinsurance. 
 
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 contract clearly states that you are 
responsible for a 70% coinsurance for partial dentures rendered in-network. Therefore, we decided that the Plan 
does not have to pay for the maxillary partial denture (D5213) provided on December 21, 2020.  
 Your complaint about the ill-fitting partial that you received from the treating provider is not a valid appeal for 
medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does 
not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an opt out provider on May 13, 2021. 
 
You asked the Plan to pay for dental services. You say that you have had these services reimbursed in the past. 
The Plan denied your request. The Plan says the rendering dentist has opted-out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program until October 1, 2023. Therefore, we decided that the Plan does not 
have to pay for dental services provided by an opt-out provider on May 13, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to waive the copayment for a crown on tooth #31 (D2751) provided on March 18, 2022. 
 
You asked the Plan to waive the copayment for a crown. You say that the crown was approved by the Plan. The 
Plan denied your request. The Plan says that you have been charged the correct cost sharing amount. 
 
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 the Dental Plan Information Guide. Without the guide 
we are unable to determine if the cost sharing amount applied is correct. Therefore, we decided that the Plan 
has to waive the copayment for a crown on tooth #31 (D2751) provided on March 18, 2022.  
 
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 pre-approve the implant /abutment supported removable denture for 
edentulous arch  maxillary (D6110) and implant /abutment supported removable denture for edentulous arch  
mandibular (D6111). 
 
You asked the Plan to pre-approve the upper and lower implant/abutment supported removable dentures. You 
say that it is medically necessary for the enrollee to have properly fitting dentures. The Plan denied your 
request. The Plan says these services are not covered under the enrollee's 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 the implant /abutment supported removable denture for edentulous arch  maxillary (D6110) and implant 
/abutment supported removable denture for edentulous arch  mandibular (D6111).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a comprehensive oral evaluation (D0150), intraoral x-
ray (D0220), additional intraoral x-rays (D0230 x 4), and endodontic therapy on tooth #13 provided on 
September 21, 2021, and a limited oral evaluation (D0140) and a crown on tooth #13 provided on October 21, 2021. 
 
You asked the Plan to pay more for the dental services. You say that you disagree with the reimbursement 
amount for the dental services. The Plan denied your request. The Plan says you are responsible for any 
charged amount above the Plan's cost-sharing amount when your services are received from an out-of-network 
provider. The Plan also says that your benefit for intraoral x-rays has been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 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 a comprehensive oral evaluation (D0150), 
intraoral x-ray (D0220), additional intraoral x-rays (D0230 x 4), and endodontic therapy on tooth #13 provided 
on September 21, 2021, and a limited oral evaluation (D0140) and a crown on tooth #13 provided on October 
21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 2D oral imaging (D0350) provided by a participating 
provider on February 15, 2022. 
 
You asked the Plan to pay for 2D oral imaging. You say that you needed to have these x-rays taken. The Plan 
denied your request. The Plan says the rendered dental work 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 2D oral 
imaging (D0350) provided by a participating provider on February 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis - adult (D1110) provided April 4, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the dental cleaning. You say that you have had this dentist for years, and benefits 
are not adequately explained prior to signing up for the Plan. The Plan denied your request. The Plan says this 
service is not covered when provided OON. 
 
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 
cleaning when the services are provided in-network. 
 
We looked at the file and Medicare rules. 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. Based on this information, we decided that the Plan's rules for coverage of 
the dental cleaning have not been met. Therefore, we decided that the Plan does not have to pay for the 
prophylaxis - adult (D1110) provided April 4, 2022, by an out-of-network (OON) provider.   
Your complaint about feeling that information about coverage is not adequately explained when signing up for 
the Plan is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be 
answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the periodic oral evaluation (D0120) and 
prophylaxis (D1110) provided on January 18, 2022. 
 
You asked the Plan to waive the copayments for the periodic oral evaluation and prophylaxis. You say that you 
believe the $15.00 copayment for preventive dental services was misleading or false advertising because it does 
not specify that the copayment is per service. The Plan denied your request. The Plan says the decision is 
upheld as a contractual obligation. 
 
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 $15 
copayment per service during the visit for covered routine dental services rendered by an in-network provider. 
Therefore, we decided that the Plan does not have to waive the copayments for the periodic oral evaluation 
(D0120) and prophylaxis (D1110) provided on January 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the limited oral evaluation (D0140) 
provided on February 21, 2022. 
 
You asked the Plan to issue reimbursement for the 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 you have 
exhausted the allowable benefit for the service provided in this case. 
 
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 the benefit for the service provided in this case was exhausted on date of service February 3, 2022. The 
Plan contract states that a limited oral evaluation is covered once per plan year. You previously received this 
service on February 3, 2022 which was paid for by the Plan. Therefore, we decided that the Plan does not have 
to issue reimbursement for the limited oral evaluation (D0140) provided on February 21, 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 a denture. You say that this service is medically necessary. The Plan denied 
your request. The Plan says this service is not covered by your dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 pre-approve complete dentures (dental codes D5110 and D5120). 
 
You asked the Plan to pre-approve dentures. You say that you should be covered for dentures. The Plan denied 
your request. The Plan says dentures are covered once every 5 plan years, but you previously received covered 
dentures on September 13, 2021. 
 
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 September 13, 2021. 
Therefore, we decided that the Plan does not have to pre-approve complete dentures (dental codes D5110 and 
D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional periapical x-ray (D0230), 2D photographic 
image (D0350), and 3D photographic image (D0351) provided on March 17, 2022. 
 
You asked the Plan to pay for the additional periapical x-ray, 2D photographic image, and 3D photographic 
image. You say that you were advised by a plan representative that the provider was in network. 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-rays are listed as 
covered, there are frequency limits that 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. Additionally, the 2D photographic image, and 3D 
photographic image are not among those covered under this benefit. Therefore, we decided that the Plan does 
not have to pay for the additional periapical x-ray (D0230), 2D photographic image (D0350), and 3D 
photographic image (D0351) provided on March 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of implant body: endosteal implants 
(D6010) and prefabricated abutments  includes modification and placement (D6056). 
 
You asked the Plan to pre-approve the endosteal implants and prefabricated abutments. You say that you would 
like to see if there is any way these services can be covered. The Plan denied your request. The Plan says these 
services are not covered under your benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 implants (D6010) and prefabricated abutments  includes 
modification and placement (D6056).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of torus mandibularis (D7473). 
 
You asked the Plan to pre-approve the dental services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says removal of torus mandibularis (D7473) is not covered by your routine 
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 the 
removal of torus mandibularis (D7473).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic parental drugs (D9610) and an impacted tooth 
removal (D7240), provided by a participating provider on March 15, 2022. 
 
You asked the Plan to pay for therapeutic parental drugs and an impacted tooth removal. You say that you 
would like the Plan to pay for this. The Plan denied your request. The Plan says D9610 and D7240 are not 
covered 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 therapeutic 
parental drugs (D9610) and an impacted tooth removal (D7240), provided by a participating provider on March 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on February 10, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told that you should have periodontal 
maintenance every quarter because of your implants. 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 November 4, 2021. 
Therefore, we decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on 
February 10, 2022.