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

 
We decided that the Plan does not have to pre-approve the dental services. 
 
You asked the Plan to pre-approve the dental services. You say that you would like to request reconsideration 
of the denied authorization. The Plan denied your request. The Plan says the dental service (D6010) is not a 
covered benefit and deep sedation/general anesthesia (D9222) do not meet the requirements for medical 
necessity. 
 
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 
dental services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the maxillary partial denture (D5211) provided on May 
31, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay more for the maxillary partial denture. You say that you contacted the Plan prior to 
having this denture made, and were told that 50% would be covered. You also say that you were only 
reimbursed $306.50, and would like to receive additional reimbursement of $73.00. The Plan denied your 
request. The Plan says you are responsible for a 50% coinsurance plus any charged amount above the Plans 
cost-sharing amount when your services are received from an OON provider. The Plan also says that you 
contacted the Plan prior to the date of service to verify benefits and provider eligibility, and were told on the 
call that OON providers may balance bill and that you would pay a higher 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. 
 
 You have been asked to pay a 50% coinsurance plus the difference between the OON 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 maxillary partial denture (D5211) 
provided on May 31, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for consultation (D9310), alveoloplasty in conjunction with 
extractions - one to three teeth x3 (D7311) and surgical removal of residual tooth roots (D7250) provided on 
May 26, 2022. 
 
You asked the Plan to pay for dental services. You say that you were not aware that your plan only allows two 
surgeries per year. The Plan denied your request. The Plan says the denial of payment for these services is 
correct, because these services are not covered by the Plan's dental benefits, or they are covered but the 
coverage benefit 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 Plans coverage rules apply in this case. The Plan covers oral surgery 2 
procedure codes per calendar year. The Plans dental benefits do not include coverage for consultation.  
 
  We looked at this the file, the Plans rules, and Medicare rules. You had received 1 surgical removal of residual 
tooth roots and 5 oral surgeries (7310 x2 and 7311 x3) on May 26, 2022; therefore, the benefit has been 
exhausted. Additionally, the consultation is not covered by the Plan. Therefore, we decided that the Plan does 
not have to pay for consultation (D9310), alveoloplasty in conjunction with extractions - one to three teeth x3 
(D7311) and surgical removal of residual tooth roots (D7250) provided on May 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an unspecified removable prosthodontic procedure (D5899) 
provided on July 13, 2021. 
 
You asked the Plan to pay for the dental services. You say that the claim for this service should have been 
submitted as a medical service.  The Plan denied your request. The Plan says your benefit for the requested 
item or service $1,300 dollar limit was met. 
 
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 January 11, 2021 and 
February 2, 2021. Therefore, we decided that the Plan does not have to pay for an unspecified removable 
prosthodontic procedure (D5899) provided on July 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction, of an erupted tooth requiring removal of bone 
and/or sectioning of tooth (D7210) provided on May 23, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service provided is not covered under your 
contractual policy. 
 
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 service provided is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the extraction, of 
an erupted tooth requiring removal of bone and/or sectioning of tooth (D7210) provided on May 23, 2022.
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 
cone beam computed tomography (CT) capture and interpretation (D0367) provided on June 2, 2022, and June 
7, 2022. 
 
You asked the Plan to pay for the problem focused limited oral evaluation and cone beam CT capture and 
interpretation. You say that you spoke to several Plan representatives who advised these services would be 
covered with your out-of-network under the medical plan, and not dental. The Plan denied your request. The 
Plan says these services are not covered expenses under your dental plan. The Plan also says you did not 
contact the Plan prior to these dates of service to verify 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 
problem focused limited oral evaluation (D0140) and cone beam computed tomography (CT) capture and 
interpretation (D0367) provided on June 2, 2022, and June 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the four gingival irrigations (D4921 x4) provided on April 
18, 2022. 
 
You asked the Plan to pay for the gingival irrigations. You say that the gingival irrigation was necessary. The 
Plan denied your request. The Plan says this service is not a covered benefit under your dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the four 
gingival irrigations (D4921 x4) provided on April 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periapical x-rays (D0220, D0230) and crowns on tooth #12 
and 15 (D2740) provided on June 30, 2022. 
 
You asked the Plan to pay for the dental services. 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 June 7, 2022. 
Therefore, we decided that the Plan does not have to pay for periapical x-rays (D0220, D0230) and crowns on 
tooth #12 and 15 (D2740) provided on June 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on December 
30, 2021. 
 
You asked the Plan to pay for the dental service. You say that you have had several dental needs and 
emergencies in the last 18 months. You say that nearly every claim has been denied. You also say that you feel 
the services should be covered. 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 limited oral evaluation was exhausted on date of service July 1, 2021. Therefore, we 
decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on December 30, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cleaning on July 12, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. 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 17, 2021, and 
March 11, 2022. Therefore, we decided that the Plan does not have to pay for a cleaning on July 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950), 
pontic (D6240), and one retainer crown (D6750) provided on April 7, 2022. 
 
You asked the Plan to pay for the core buildup, pontic, and one retainer crown. You say that you believe the 
services need to be broken down into more specifics, with different coding. You also say that you know your 
policy does cover a percentage of cavity treatment, and these services should be covered. The Plan denied your 
request. The Plan says the core buildup and pontic are not covered expenses under your dental plan. The Plan 
also says that your benefit for the additional retainer crown has 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 Plans coverage rules apply in this case.  
Though the Plan offers a dental benefit in excess of Medicare coverage, core buildup, including any pins when 
required (D2950) and pontic (D6240) are not among those covered under this benefit. The contract also says 
that crowns are limited to one procedure code per calendar year. The record shows that the Plan covered one 
retainer crown (D6750) provided on April 7, 2022, and your crowns benefit has been exhausted. Therefore, we 
decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950), 
pontic (D6240), and one retainer crown (D6750) provided on April 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), bitewing x-rays 
(D0274), and prophylaxis (D1110) provided on April 14, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the dental services. You say that the provider you were treated by is the only 
dentist near you that is accepting new patients, and you would like this bill to be paid. The Plan denied your 
request. The Plan says the dental services were received from an out-of-network provider and are not covered 
by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for the comprehensive oral evaluation (D0150), bitewing x-rays (D0274), and prophylaxis (D1110) 
provided on April 14, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the lower partial denture (D5226) provided on March 
23, 2022. 
 
You asked the Plan to pay more for the dental services. You say that your dentist said that your insurance was 
covering the costs. 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 23, 2022, when 
the Plan paid for your upper denture and part of your lower denture. Therefore, we decided that the Plan does 
not have to pay more for the lower partial denture (D5226) provided on March 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite-one surface, posterior (D2391) 
provided on April 18, 2022.  Additionally, the Plan does not have to issue additional payment for the resin-
based composite-four or more surfaces, posterior (D2394) and the amalgam-one surface, primary or permanent 
(D2140) provided on April 18, 2022. 
 
You asked the Plan to pay for the resin-based composite-one surface, posterior. Additionally, you asked the 
Plan to issue additional payment for the resin-based composite-four or more surfaces, posterior and the 
amalgam-one surface, primary or permanent. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says payment has been issued at the maximum 
allowable amount for the dental services provided this calendar year.  
 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.  
 
We looked at this case file and the Plans rules. Based on this information, we decided that the Plan's rules for 
additional coverage of the dental services provided have not been met. Specifically, the Plan issued payment 
for the resin-based composite-four or more surfaces posterior and the amalgam-one surface filling at the Plans 
allowable amount and you are responsible for a 20% coinsurance for these services. Additionally, payment has 
been denied for the resin-based composite-one surface, posterior as the Plan provides up to $1,000 of dental 
coverage per calendar year. The Plan has issued payment at the maximum allowable amount for dental services 
provided this calendar year. Therefore, we decided that the Plan does not have to pay for the resin-based 
composite-one surface, posterior (D2391) provided on April 18, 2022. Additionally, the Plan does not have to 
issue additional payment for the resin-based composite-four or more surfaces, posterior (D2394) and the 
amalgam-one surface, primary or permanent (D2140) provided on April 18, 2022. 
.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for the abutment supported 
porcelain/ceramic crown (D6058) for tooth # 19 provided on June 6, 2022. 
 
You asked the Plan to pay an additional amount for the dental service. You say that the copayment amount for 
this service is supposed to be $595. The Plan denied your request. The Plan says the claim was 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 the abutment supported porcelain 
crown is listed as covered, there is an optional service provision that applies. The Plan coverage states that if 
you receive a service that is more expensive than what is customary, you will be responsible for the difference 
in cost. The allowed amount for a metal crown on this tooth is $1,191. The allowed amount for a porcelain 
crown on this tooth is $$1,500. $1,500 - $1,191 = $309. Therefore, we decided that the Plan does not have to pay an additional amount for the abutment supported porcelain/ceramic crown (D6058) for tooth # 19 provided 
on June 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve general anesthesia. 
 
You asked the Plan to pre-approve general anesthesia. You say that you would like to request reconsideration 
of the denied authorization. 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 pre-approve 
general anesthesia.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite of one surface (D2391) on tooth 
#15 provided on June 13, 2022. 
 
You asked the Plan to pay for the resin-based composite. You say that the frequency limitation does not apply 
because there is no history of fillings previously being done on this tooth. 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 June 13, 2022. Therefore, 
we decided that the Plan does not have to pay for the resin-based composite of one surface (D2391) on tooth 
#15 provided on June 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unspecified adjunctive procedures (D9999 x 2) provided 
on June 21, 2022, outside the United States.  
You asked the Plan to pay for the dental services. You say that you do not have teeth. You say that you drove 
to Mexico to have 6 implants put in. You say that you knew you would have to pay upfront because it was out 
of network. You also say that you should be reimbursed for what you paid. The Plan denied your request. The 
Plan says services receive outside the United States are not covered unless it is an emergency. The Plan also 
says the services in this case were not urgent or emergent. 
 
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 dental services you received 
outside the United States are not among those covered under this benefit. Therefore, we decided that the Plan 
does not have to pay for the unspecified adjunctive procedures (D9999 x 2) provided on June 21, 2022, outside 
the United States.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two periodontal scalings and root planings (D4341 x2) 
provided on June 16, 2022. 
 
You asked the Plan to pay for the scalings and planings. You say that the Plan should cover these services. The 
Plan denied your request. The Plan says your calendar year maximum for the requested 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 calendar year maximum for the requested services was exhausted on date of service May 18, 2022. 
Therefore, we decided that the Plan does not have to pay for the two periodontal scalings and root planings 
(D4341 x2) provided on June 16, 2022.