Persius/hicric huggingface dataset:
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 removal of torus the mandibularis (D7473). You say that you need the 
surgery done before you can get your dentures done with the provider. The Plan denied your request. The Plan 
says the service is denied as the service is not a covered Medicare 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 the 
removal of torus mandibularis (D7473).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup services, an intraoral x-ray, limited oral 
evaluation, and crown provided (D0220, D2740, D0140, D2950) on August 11, 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 a dental crown has already 
been exhausted, the coverage for: core buildup services, an intraoral x-ray, and a limited oral evaluation is 
denied 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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service 01/27/2022. Therefore, 
we decided that the Plan does not have to pay for core buildup services, an intraoral x-ray, limited oral 
evaluation, and crown provided (D0220, D2740, D0140, D2950) on August 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical placement of implant body: endosteal implant 
tooth #19 (D6010), prefabricated abutment  includes modification and placement tooth #19 (D6056), and 
abutment supported porcelain/ceramic crown tooth #19 (D6058). 
 
You asked the Plan to pre-approve the surgical placement of implant body: endosteal implant tooth #19 
(D6010), prefabricated abutment  includes modification and placement tooth #19 (D6056), and abutment 
supported porcelain/ceramic crown tooth #19 (D6058). You say that the Plan representative stated that a tooth 
implant would be covered with pre-authorization. The Plan denied your request. The Plan says these services 
are not covered under the benefit package. 
 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 
surgical placement of implant body: endosteal implant tooth #19 (D6010), prefabricated abutment  includes 
modification and placement tooth #19 (D6056), and abutment supported porcelain/ceramic crown tooth #19 
(D6058).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the cleaning (D1110) and the periodic oral evaluation 
(D0120) provided on July 26, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you want to be reimbursed for your dental 
cleaning. You say you paid $128 for out-of-network services. 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 the cleaning (D1110) and the periodic oral 
evaluation (D0120) provided on July 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implant supported crown (D6065) and an abutment 
supported crown (D6058) on tooth #4. 
 
You asked the Plan to pre-approve the dental services. You say that you should not have to pay for this 
implant. 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 authorization request, exceeding 
your benfit limitations. Therefore, we decided that the Plan does not have to pre-approve an implant supported 
crown (D6065) and an abutment supported crown (D6058) on tooth #4.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740), the core buildup (D2950), endodontic 
therapy (D3320), and other drugs (D9630) for tooth #13. 
 
You asked the Plan to pre-approve the dental services. You say that you would like a reversal of the denied 
dental services and would like the Plan to fully approve the treatment. The Plan denied your request. The Plan 
says the denial of authorization for these services is correct, because crowns, core buildup, endodontic therapy, 
and other drugs 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 a 
crown (D2740), the core buildup (D2950), endodontic therapy (D3320), and other drugs (D9630) for tooth #13.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the internal bleaching (D9974). 
 
You asked the Plan to pre-approve the internal bleaching. You say that the enrollee needs a root canal The Plan 
denied your request. The Plan says this service is 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 
internal bleaching (D9974).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite (D2332) and the periodontal 
scaling and root planning (D4341) for tooth #10 and #11 provided on June 27, 2022, to July 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were not aware that the dental plan was 
cancelled, and the dental services should be covered. The Plan denied your request. The Plan says your benefit 
for the resin-based composite has already been exhausted because the enrollee hit their annual maximum dental 
benefit. Also, the periodontal scaling and root planning 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, certain limitations apply. The record 
shows that your annual maximum dental benefit was exhausted on the date of service of July 7, 2022. Also, the 
periodontal scaling and root planning is not covered under the Plans dental benefits. Therefore, we decided 
that the Plan does not have to pay for the resin-based composite (D2332) and the periodontal scaling and root 
planning (D4341) for tooth #10 and #11 provided on June 27, 2022, to July 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic (D6240) and a retainer crown (D6750) for tooth 
#6, #7, and #8. 
 
You asked the Plan to pre-approve the dental services. You say that you would like the dental services to be 
approved. The Plan denied your request. The Plan says the denial of authorization for these services is correct, 
because pontics and retainer crowns 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 a 
pontic (D6240) and a retainer crown (D6750) for tooth #6, #7, and #8.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete denture - mandibular (D5120), and complete 
denture - maxillary (D5110). 
 
You asked the Plan to pre-approve the dental services. The Plan denied your request. The Plan says dental 
services from an out-of-network provider 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. 
 
You are requesting 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 pre-approve a complete 
denture - mandibular (D5120), and complete denture - maxillary (D5110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for adding tooth to existing partial denture (D5650) provided on 
June 20, 2022. 
 
You asked the Plan to pay for adding tooth to existing partial denture (D5650). You say that you are on a 
limited income. You also say that you were eating, and your tooth broke off. The Plan denied your request. The 
Plan says this service is not covered under the member's contract under any normal 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 adding 
tooth to existing partial denture (D5650) provided on June 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extraction, erupted tooth or exposed root (D7140) provided 
on July 18, 2022. 
 
You asked the Plan to pay for dental services. You say that the services should be covered. The Plan denied 
your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 50% 
coinsurance after $100 deductible for Class 3 Major Services.  
 You have been asked to pay $100.50 for extraction, erupted tooth or exposed root (D7140). You were billed 
$122 as the allowed amount, $79 went towards the $100 deductible which leaves $43.50, then 50% coinsurance 
on $43.50 = $21.50. Therefore, $79 deductible + $21.50 = $100.50 total cost. This extraction, erupted tooth or 
exposed root (D7140) 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 pay for 
extraction, erupted tooth or exposed root (D7140) provided on July 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial maxillary denture (D5214) and a complete 
mandibular denture (D5110). 
 
You asked the Plan to pre-approve dentures. You say that you disagree with the denial for dental services. The 
Plan denied your request. The Plan says your benefit for the requested items or 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. The record 
shows your benefit for a partial mandibular denture was exhausted on date of service December 20, 2019. The 
record also shows your benefit for a complete maxillary denture was exhausted on date of service December 
28, 2019. Therefore, we decided that the Plan does not have to pre-approve a partial maxillary denture (D5214) 
and a complete mandibular denture (D5110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and a periapical x-ray 
(D0220) provided on May 31, 2022. 
 
You asked the Plan to pay for an evaluation and x-ray. You say that you disagree with the denial of dental 
services. The Plan denied your request. The Plan says your benefit for the requested items or 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. The record 
shows your benefit for the requested items or services was exhausted on date of service April 28, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) and a periapical 
x-ray (D0220) provided on May 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the general anesthesia (D9222 and D9223). 
 
You asked the Plan to pre-approve the dental services. You say that you need to be put to sleep prior to the 
dentist pulling your teeth. The Plan denied your request. The Plan says the denial of authorization for these 
services is correct, because the anesthesia 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 pre-approve the 
general anesthesia (D9222 and D9223).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown - porcelain/ceramic tooth #4 (D2740). 
 
You asked the Plan to pre-approve the crown - porcelain/ceramic tooth #4 (D2740). The Plan denied your 
request. The Plan says the service is denied as the service is not a covered Medicare 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 
crown - porcelain/ceramic tooth #4 (D2740).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement graft for ridge preservation - per site 
tooth #'s 29, 30 (D7953), and implant maintenance procedures when prostheses are removed and reinserted, 
including cleansing of prostheses and abutments (D6080). 
 
You asked the Plan to pre-approve the bone replacement graft for ridge preservation - per site tooth #'s 29, 30 
(D7953), and implant maintenance procedures when prostheses are removed and reinserted, including 
cleansing of prostheses and abutments (D6080). You say that you are appealing the denial for implant 
maintenance procedures and two bone replacement grafts. The Plan denied your request. The Plan says you are 
appealing the denial for implant maintenance procedures and two bone replacement grafts. 
 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 
bone replacement graft for ridge preservation - per site tooth #'s 29, 30 (D7953), and implant maintenance 
procedures when prostheses are removed and reinserted, including cleansing of prostheses and abutments 
(D6080).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown (D2740) provided on August 10, 2022. 
 
You asked the Plan to pay for the crown (D2740). You say that you are unable to pay this amount. You say you 
are retired and on a limited, fixed income. 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 crown 
(D2740) provided on August 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic - porcelain/ceramic tooth #'s 8, 9 (D6245), 
retainer crown - porcelain/ceramic tooth #'s 6, 7, 10, 11 (D6740), and fixed partial denture sectioning (D9120). 
 
You asked the Plan to pre-approve the pontic - porcelain/ceramic tooth #'s 8, 9 (D6245), retainer crown - 
porcelain/ceramic tooth #'s 6, 7, 10, 11 (D6740), and fixed partial denture sectioning (D9120). You say that 
these services are medically necessary. The Plan denied your request. The Plan says these services are not 
covered under the benefit package. 
 
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 
pontic - porcelain/ceramic tooth #'s 8, 9 (D6245), retainer crown - porcelain/ceramic tooth #'s 6, 7, 10, 11 
(D6740), and fixed partial denture sectioning (D9120).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the BluePrint genetic testing services (81479) provided on 
May 29, 2022. 
 
You asked the Plan to pay for the BluePrint genetic testing services. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says this testing is not covered 
by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that the BluePrint test is a statutorily excluded test. 
Based on this information, we decided that Medicare rules for coverage of the BluePrint genetic testing 
services have not been met. Therefore, we decided that the Plan does not have to pay for the BluePrint genetic 
testing services (81479) provided on May 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the upper partial denture (D5213) 
 
You asked the Plan to pre-approve the dental services. You say that the old denture is unusable, and you need a 
new denture. 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 June 18, 2021. 
Therefore, we decided that the Plan does not have to pre-approve the upper partial denture (D5213)
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4556 billed for date of service July 20, 
2021. 
 
You asked the Plan to pay for procedure code A4556. You say that you disagree with the denial. The Plan 
denied your request. The Plan says procedure code A4556 is considered bundled/excluded and not separately 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code.  
We find that procedure code A4556 has a status indicator of P on the Physician Fee Schedule. This means that 
procedure code A4556 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code A4556 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code A4556 billed for date of service July 20, 2021.