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

 
We decided that the Plan does not have to pay for the two removable prosthodontic procedures (D5899 x2) 
provided on November 13, 2019. 
 
You asked the Plan to pay for the removable prosthodontic procedures. You say that the dentures provided to 
you did not fit and you returned them within the correct timeframe. You also say that a money back guarantee 
is advertised, and neither the insurance nor you should have to pay or owe the provider anything. The Plan 
denied your request. The Plan says this is not a covered service on 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the two 
removable prosthodontic procedures (D5899 x2) provided on November 13, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the consultation (D9310) and periapical x-ray (D0220) 
provided on November 16, 2021. 
 
You asked the Plan to pay for the dental services. You say that you were referred to this provider. You also say 
that you were not aware that the provider was out of network. The Plan denied your request. The Plan says 
dental services received out of network 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 Plan's 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, dental services received out of network are not among those covered under this benefit. Consultation 
is not among those covered under this benefit regardless of the provider's network status. Therefore, we 
decided that the Plan does not have to pay for the consultation (D9310) and periapical x-ray (D0220) provided 
on November 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220), additional 
intraoral periapical x-ray (D0230), and comprehensive oral evaluation (D0150) provided on October 11, 2021. 
 
You asked the Plan to pay for the intraoral periapical x-rays and comprehensive oral evaluation. You say that 
you would like to appeal these services. The Plan denied your request. The Plan says intraoral periapical x-rays 
are not a covered expense under your dental plan. The Plan also says that your benefits for the comprehensive 
oral evaluation have been satisfied and the frequency limitation has been exceeded. 
 
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 first intraoral periapical x-ray 
(D0220) and additional intraoral periapical x-ray (D0230) are not among those covered under this benefit. The 
contract says that comprehensive oral evaluation (D0150) is limited to one procedure code every three years. 
The record shows that you received a comprehensive oral evaluation (D0150) on August 11, 2020 and your 
comprehensive oral evaluation (D0150) benefit has been exhausted. Therefore, we decided that the Plan does 
not have to pay for the first intraoral periapical x-ray (D0220), additional intraoral periapical x-ray (D0230), 
and comprehensive oral evaluation (D0150) provided on October 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the occlusal orthotic device, by report (D7880) provided July 6, 2021. 
 
You asked the Plan to pay for the occlusal orthotic device. You say that this device helped realign your 
overbite and eliminate the pain in your mouth. The Plan denied your request. The Plan says this service is not 
covered under your benefits. 
 
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 occlusal orthotic device, by 
report (D7880) provided July 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral exam (D0120) and prophylaxis (D1110) provided on 
December 8, 2021. 
 
You asked the Plan to pay for the dental services. You say that routine services are covered. You also say that 
these services should be paid. The Plan denied your request. The Plan says dental services received out of 
network 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, dental services received out of network 
are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
the oral exam (D0120) and prophylaxis (D1110) provided on December 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), crown 
(D2740) core buildups, including any pins when required (D2950), endodontic therapy (D3320), pontic 
(D6245), retainer crowns (D6740), and extraction (D7140) provided on November 9, 2021. 
 
You asked the Plan to pay for the problem focused limited oral evaluation, crown, core buildups, endodontic 
therapy, pontic, retainer crowns, and extraction. You say that you would like to appeal these services. 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 contact the Plan twice prior to this date of service to verify benefits and provider 
eligibility, and you were mailed a code-specific breakdown of your dental benefits each time. 
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 
problem focused limited oral evaluation (D0140), crown (D2740) core buildups, including any pins when 
required (D2950), endodontic therapy (D3320), pontic (D6245), retainer crowns (D6740), and extraction 
(D7140) provided on November 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two periodontal scalings and root planings (D4342 x2) 
and three localized deliveries of antimicrobial agents (D4381 x3). 
 
You asked the Plan to pre-approve the scalings and planings and localized deliveries of antimicrobial agents. 
You say that you believe that these services are covered under your dental booklet for 2022. The Plan denied 
your request. The Plan says these services are not covered under your benefit plan. 
 
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 pre-approve two 
periodontal scalings and root planings (D4342 x2) and three localized deliveries of antimicrobial agents 
(D4381 x3).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room services provided on 
November 1, 2021. 
 
You asked the Plan to waive the copayment for emergency room services. You say that the copayment should 
be waived. The Plan denied your request. The Plan says the copayment amount charged is correct. 
 
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 $90 
copayment for emergency care.  
 
You have been asked to pay a $90 copayment for emergency room services. Emergency room services fall 
within the Emergency Care 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 copayment for emergency 
room services provided on November 1, 2021.  
 
Your complaint about your experience with this 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 the crown (D2751) provided on November 10, 2021. 
 
You asked the Plan to pay for the dental service. You say that your benefits say there is a $0 copayment for 
comprehensive dental services. You say that your dentist advised they were not sure why the service was not 
covered. You also say that you feel this should be covered. The Plan denied your request. The Plan says crown 
is not listed as a covered service. 
 
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 crown is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the crown (D2751) provided on November 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and 
incisional biopsy of oral tissue (D7286) provided on September 27, 2021. 
 
You asked the Plan to pay for the problem focused limited oral evaluation and incisional biopsy. You say that 
you contacted the Plan and were advised that you could see this provider. You also say that you would like this 
claim to be reconsidered because the doctor you saw was opt in when you received these services. The Plan 
denied your request. The Plan says the Health Plan claims department reprocessed and approved payment in 
the amount of $199.00 to max out your dental benefit since $551.00 was already used out of the allowed 
amount of $750.00. The Plan also says that you are responsible for the $411.00 which was the remaining 
amount left between the amount of $610.00 and the remaining allowed amount of $199.00. 
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 Plan offers up to $750 every year 
for non-Medicare covered preventive and comprehensive dental services combined. The contract says that you 
are responsible for any amount above the dental coverage limit. The record shows that you met the annual 
maximum benefit after reprocessing this claim for the September 27, 2021 date of service and your annual 
maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the problem 
focused limited oral evaluation (D0140) and incisional biopsy of oral tissue (D7286) provided on September 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral exam (D0140) provided on October 28, 2021. 
 
You asked the Plan to pay for the limited exam. You say that this service was necessary. The Plan denied your 
request. The Plan says you had a previous limited oral exam on October 2, 2021, which was covered by the 
Plan at that time. Your benefit covers only one limited oral exam each plan year. 
 
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 Plan covers one limited 
exam to evaluate a problem (D0140) per plan year. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the limited exam is requested in a 
frequency that is not covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
the limited oral exam (D0140) provided on October 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 86141, 83090, 84481, 
84550, 85025, 80053, 80061, 82550, 84439, 84443, and 84480) provided on June 5, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. CPT code(s): 86141, 83090, 84481, 84550, 
85025, 80053, 80061, 82550, 84439, and 84443, remain not supported. The place of service on the CMS-1500 
form line 24B must reflect the location of the patient when the specimen was obtained. The submitted claim 
form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical 
documentation and/or claim history indicates that the specimen was obtained in an office setting POS 11; 
therefore, the billed code cannot be verified. It is noted multiple attempts were made to obtain additional 
information from the provider. 
 
Furthermore, NCCI PTP edit exists between 84480 and 84481. This PTP edit has a modifier indicator of 0, 
which indicates there are no modifiers that are allowed with this PTP code pair. Based on the claim submitted, 
Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the 
laboratory services (CPT code(s): 86141, 83090, 84481, 84550, 85025, 80053, 80061, 82550, 84439, 84443, 
and 84480) provided on June 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two surgical accesses to an implant body (D6011 x2). 
 
You asked the Plan to pre-approve the surgical accesses to an implant body. The Plan denied your request. The 
Plan says this service is not covered under your benefit plan. 
 
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 pre-approve two 
surgical accesses to an implant body (D6011 x2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental anesthesia services rendered on October 13, 2021. 
 
You asked the Plan to pay for these services. You say that you needed the services due to severe anxiety. The 
Plan denied your request. The Plan says the 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 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 
anesthesia services rendered on October 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve biologic materials to aid in soft and osseous tissue 
regeneration (D3431). 
 
You asked the Plan to pre-approve the biologic materials. You say that in order to get the root canal you were 
approved for, you need to receive this service as well. The Plan denied your request. The Plan says this service 
is not covered under your benefit 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 
biologic materials to aid in soft and osseous tissue regeneration (D3431).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endosteal implants (D6010), prefabricated abutments 
(D6056), and implant supported porcelain/ceramic crowns (D6065). 
 
You asked the Plan to pre-approve the endosteal implants, prefabricated abutments, and implant supported 
porcelain/ceramic crowns. You say that the enrollee has to swallow his food because he cannot chew it. The 
Plan denied your request. The Plan says these services are not covered under the enrollee's plan. 
 
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 pre-approve 
endosteal implants (D6010), prefabricated abutments (D6056), and implant supported porcelain/ceramic 
crowns (D6065).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140), periapical x-ray 
(D0220), and unspecified preventive service (D1999) provided on November 3, 2021. 
 
You asked the Plan to pay for the dental services. You say that you were given a list totaling $42.50 that you 
were told your insurance would cover. You say that you received an Evidence of Benefits (EOB) for $227. You 
also say that the dental office advised you had a zero balance. 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 Plan's coverage rules apply in this case. 
Though the Plan offers a dental benefit in excess of Medicare coverage, the limited oral evaluation, periapical 
x-ray, and unspecified preventive service are not among those covered under this benefit. Additionally, the 
record shows that the proposed treatment plan indicates that the amount in the insurance column is only an 
estimate of coverage and does not guarantee payment. Therefore, we decided that the Plan does not have to pay 
for the limited oral evaluation (D0140), periapical x-ray (D0220), and unspecified preventive service (D1999) 
provided on November 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213). 
 
You asked the Plan to pre-approve the maxillary partial denture. You say that you would like the upper partial 
to be covered by the Plan because you cannot afford to pay for it. The Plan denied your request. The Plan says 
this procedure is not included in the benefits section of your Evidence of Coverage (EOC). 
 
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).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endosteal implants (D6010). 
 
You asked the Plan to pre-approve the endosteal implants. You say that another treatment plan will affect the 
present teeth. You also say that you have requested implants because it is best for the enrollee's condition to 
have stability on her mouth. The Plan denied your request. The Plan says this service is not covered under the 
enrollee's benefit 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 
endosteal implants (D6010).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous intraoperative neurophysiology monitoring 
rendered on January 29, 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 are not covered. 
 
The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid 
for Medicare purposes. 
 
We looked at the file and Medicare rules. Billed procedure code 95941 has a status indicator of I and is not valid for Medicare purposes. Therefore, we decided that the Plan does not have to pay for the continuous intraoperative neurophysiology monitoring rendered on January 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), and intraoral imaging 
(D0220 and D0230) provided by a participating provider on May 11, 2021. 
 
You asked the Plan to pay for a limited oral evaluation and intraoral imaging. You say that these services are 
part of your plan. You say that you should not have to pay for this. The Plan denied your request. The Plan says 
the rendered dental services are not covered 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 a limited 
oral evaluation (D0140), and intraoral imaging (D0220 and D0230) provided by a participating provider on 
May 11, 2021.