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

 
We decided that the Plan does not have to pay more for mandibular partial denture - cast metal framework with 
resin denture bases (D5214) provided on September 27, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you would like your insurance to pay the 
remaining balance of the billed services. 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 the Plan paid $96 on date of service March 21, 2022, $58 on date of service May 5, 2022, $959 on dates 
of service July 7, 2022, $876 on date of service September 20, 2022, and $2,011 on date of service September 
27, 2022. Therefore, your annual maximum was exhausted as of September 27, 2022 ($96 + 58 + $959 + $876 
+ $2,011 = $4,000). Therefore, we decided that the Plan does not have to pay more for mandibular partial 
denture - cast metal framework with resin denture bases (D5214) provided on September 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gingival irrigation (D4921) provided on October 13, 2022. 
 
You asked the Plan to pay for gingival irrigation. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says the rendered dental service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for gingival 
irrigation (D4921) provided on October 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture and 
interpretation with field of view of both jaws; with or without cranium (D0367) and the intraoral-periapical 
additional radiographic images (D0230 x 2) provided on October 28, 2022. 
 
You asked the Plan to pay for these 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 cone beam computed tomography scan is 
not a covered benefit. Additionally, you have exhausted the allowable benefit for the intraoral-periapical 
radiographic images provided. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the cone beam CT scan is not among 
those covered services under this benefit. Additionally, you have exhausted the allowable benefit for the 
intraoral-periapical additional radiographic images provided. Specifically, the Plan contract states that one 
intraoral x-ray is covered per calendar year. On this day, you received an intraoral-periapical first radiographic 
image (D0220) that was paid for by the Plan. Therefore, you have exhausted the allowable benefit for this 
service. Therefore, we decided that the Plan does not have to pay for the cone beam computed tomography 
(CT) capture and interpretation with field of view of both jaws; with or without cranium (D0367) and the 
intraoral-periapical additional radiographic images (D0230 x 2) provided on October 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive periodontal evaluation (D0180) provided 
on November 14, 2022. 
 
You asked the Plan to pay for the dental service. You say that you went to an in-network dentist for a routine 
dental exam, and it should be covered. The Plan denied your request. The Plan says the denial of payment for 
this service is correct, because the comprehensive periodontal evaluation 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 item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
comprehensive periodontal evaluation (D0180) provided on November 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on 
September 29, 2022. 
 
You asked the Plan to pay for the dental services. You say that this was your first visit of the year. 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 November 18, 2021. 
Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) 
provided on September 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services with an OON provider. 
 
You asked the Plan to pre-approve dental services with an OON provider. You say that your provider said you 
need to see an oral surgeon, so you would like to see the OON provider. 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 dental 
services with an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pontic - porcelain fused to predominantly base metal 
(D6241) Tooth #4, 5, 6, 7, 8, 9 and retainer crown - porcelain fused to predominantly base metal (D6751) 
Tooth #3, 10, 11. 
 
You asked the Plan to pre-approve dental services. You say that you need to have the requested services 
approved because you are experiencing severe pain. The Plan denied your request. The Plan says this service is 
not covered under your Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. Pontic - porcelain fused to 
predominantly base metal and retainer crown - porcelain fused to predominantly base metal are not covered 
under the Plans dental benefits. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D6241 and D6751 are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
pontic - porcelain fused to predominantly base metal (D6241) Tooth #4, 5, 6, 7, 8, 9 and retainer crown - 
porcelain fused to predominantly base metal (D6751) Tooth #3, 10, 11.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) 
provided on December 1, 2022. 
 
You asked the Plan to pay for the dental services. You say that your tooth broke during the night, and you had 
no choice but to get it evaluated. 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 September 16, 2022. 
Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation 
(D0140) provided on December 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodic oral evaluation (D0120) and prophylaxis  adult 
(D1110) provided on November 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that you did not know you could not receive these 
services again, if you would have known, you would have declined. 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. This benefit includes the 
requested periodic oral evaluation (D0120) and prophylaxis  adult (D1110) but each service is limited to two 
procedures per plan year. 
  We looked at the file, the Plans rules, and Medicares rules. You previously received covered periodic oral 
evaluation (D0120) and prophylaxis  adult (D1110) on date of service March 5, 2022, and on date of service 
August 17, 2022. Therefore, these benefits were exhausted as of August 17, 2022. Therefore, we decided that 
the Plan does not have to pay for periodic oral evaluation (D0120) and prophylaxis  adult (D1110) provided 
on November 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown repair (D2980) for tooth #19 provided on 
December 22, 2022. 
 
You asked the Plan to pay for the dental service. You say that the dental procedure was medically necessary, 
and you could not eat without it fixed. The Plan denied your request. The Plan says the denial of payment for 
this service is correct, because the crown repair 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 item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the crown 
repair (D2980) for tooth #19 provided on December 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot inserts (L3000). 
 
You asked the Plan to pre-approve the foot inserts. You say that you have pain in your right leg. You also say 
that you have used orthotics for the last 40 years. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot inserts (L3000).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the periodontal maintenance (D4910) provided on 
November 3, 2022. 
 
You asked the Plan to pay more for the dental service. You say that the dental procedure was done in 
conjunction with 2 surgical procedures. The Plan denied your request. The Plan says you are responsible for the 
difference in allowed amount. 
 
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 total allowed amount for the periodontal maintenance (D4910) was $136. The total allowed amount for the 
approved prophylaxis (D1110) was $77. The difference in the allowed amount was $59 ($136 billed service - 
$77 approved service). You have been asked to pay the difference between the allowed amount of the less 
expensive alternate procedure. 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 periodontal 
maintenance (D4910) provided on November 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies provided on September 13, 2022. 
 
You asked the Plan to pay for wound care supplies. You say that wound care supplies are a separately billable 
expense that does not require authorization or referral. The Plan denied your request. The Plan says that 
unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for wound care supplies 
provided on September 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone replacement graft for ridge preservation - per site 
(D7953), extraction, erupted tooth requiring removal of bone and/or sectioning of tooth (D7210), and 
extraction, erupted tooth or exposed root (D7140) provided on October 18, 2022. 
 
You asked the Plan to pay for codes D7953, D7210 and D7140. You say that the need for the implants is 
related to a previous fall. You also say that the services should be considered as they are not cosmetic. 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 pay for a bone 
replacement graft for ridge preservation - per site (D7953), extraction, erupted tooth requiring removal of bone 
and/or sectioning of tooth (D7210), and extraction, erupted tooth or exposed root (D7140) provided on October 
18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and related 
supplies. 
 
You asked the Plan to pre-approve the CGM and related supplies. You say that the CGM is necessary because 
it will alert you anytime you are not awake. The Plan denied your request. The Plan says the Medicare criteria 
was not met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of the CGM and 
related supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
continuous glucose monitor (CGM) and related supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewing x-rays provided on November 9, 2022. 
 
You asked the Plan to pay for the dental services. You say that the x-rays were needed because you moved and 
are seeing a new provider. 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 March 2, 2022. 
Therefore, we decided that the Plan does not have to pay for the bitewing x-rays provided on November 9, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite (D2392), crown (D2740), and core 
buildup (D2950) provided on January 27, 2021. 
 
You asked the Plan to pay for the dental services. You say that you are appealing the denial. The Plan denied 
your request. The Plan says these services are not covered by the Plan's dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the resin-
based composite (D2392), crown (D2740), and core buildup (D2950) provided on January 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for a continuous glucose monitor 
(CGM) provided by an out-of-network provider on October 18, 2022. 
 You asked the Plan to pay for the supply allowance for the CGM. You say that you have sent all supporting 
documentation and not sure why the claim is denied. The Plan denied your request. The Plan says the Medicare 
criteria was not met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the supply allowance for the CGM have not been met. Therefore, we decided that the Plan does not have to pay 
for the supply allowance for a continuous glucose monitor (CGM) provided by an out-of-network provider on 
October 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot inserts (L3000). 
 
You asked the Plan to pre-approve the foot inserts. You say that you have used orthotics in the past and it helps 
with your foot and body pain. You also say that your feet are going flat which causes your foot to turn out 
which causes a pain on the nerve of your outside ankle. The Plan denied your request. The Plan says this item 
is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot inserts (L3000).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve orthopedic footwear, additional charge for split size 
(L3257). 
 
You asked the Plan to pre-approve orthopedic footwear, additional charge for split size (L3257). You say that 
you are unable to go up and down the stairs, kneel and walk 5 to 10 blocks. You also say that you find it 
difficult to perform activities of daily living. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve orthopedic footwear, additional 
charge for split size (L3257).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic visits provided on September 29, 2022. 
 
You asked the Plan to pay for chiropractic visits. You say that you have pain and find these services helpful. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for chiropractic visits 
provided on September 29, 2022.