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

 
We decided that the Plan does not have to pay for the complete upper denture (D5110) provided January 25, 2022. 
 
You asked the Plan to pay for the dental item. You say that you received prior authorization for the denture. 
You say that fabrication started on November 16, 2021. You say that you did not receive the dentures until 
January 2022. You say that you were advised your dental coverage changed as of January 1, 2022. You also 
say that you did not have knowledge of this change. The Plan denied your request. The Plan says the claim 
denied 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 denture is not among those covered 
under the 2022 benefit. Therefore, we decided that the Plan does not have to pay for the complete upper 
denture (D5110) provided January 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) provided 
on December 9, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the comprehensive periodontal evaluation. You say that your regular dentist 
referred you to the periodontist you were treated by. You also say that this treating provider is the only 
periodontist in the area you live, and you had to use her services. The Plan denied your request. The Plan says 
services performed by an OON provider are not covered because your healthcare plan does not have OON 
benefits. The Plan says that you did not contact the Plan prior to the date of service to verify benefits and 
provider eligibility.  
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, you are responsible for 100% of the 
cost for dental services rendered by an OON provider. Therefore, we decided that the Plan does not have to pay 
for the comprehensive periodontal evaluation (D0180) provided on December 9, 2021 by an out-of-network 
(OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower 
denture (D5120). 
 
You asked the Plan to pre-approve the dental items. You say that you lost both dentures. You say that without 
dentures you cannot chew your food. You also say that you are unable to digest your food properly. The Plan 
denied your request. The Plan says dentures are covered once every 5 plan years. The Plan also says that the 
frequency limit has been reached. 
 
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 dentures are listed as covered, the 
frequency limit of once every 5 plan years has been reached. The record shows that the Plan paid for dentures that you received on June 18, 2020. Therefore, we decided that the Plan does not have to pre-approve a 
complete upper denture (D5110) and a complete lower denture (D5120).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on October 12, 2021. 
 
You asked the Plan to pay for the services provided. You say that no coding changes are required. The Plan 
denied your request. The Plan says no separate payment is made. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99053 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99053 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
have not been met. Therefore, we decided that the Plan does not have to pay for the medical services provided 
on October 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical placement of implant body: endosteal implant 
(D6010) provided on August 26, 2021. 
 
You asked the Plan to pay for the endosteal implant. 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 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 
surgical placement of implant body: endosteal implant (D6010) provided on August 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the consultation (D9310) provided on February 14, 2022. 
 
You asked the Plan to pay for the dental service. You say that this service is necessary. The Plan denied your 
request. The Plan says consultation 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the consultation is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the consultation 
(D9310) provided on February 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periapical x-rays (D0220, D0230 x 2) provided on 
December 20, 2021. 
 
You asked the Plan to pay for the dental services. You say that possibly the reviewer was confused as in 2021 
you ceased subscribing to the additional cost Optional Dental Rider which would have cover additional and/or 
a higher amount of dental services in excess of those dental services that were already included as part of your 
plan. The Plan denied your request. The Plan says periapical x-rays are not listed as 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 periapical x-rays are not among those covered under this benefit. The record shows that you terminated your optional supplemental dental rider, 
effective January 31, 2021, which provided coverage for the services you received. Therefore, we decided that 
the Plan does not have to pay for the periapical x-rays (D0220, D0230 x 2) provided on December 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 5 fillings provided on August 10, 2021. 
 
You asked the Plan to pay for the dental services. You say that the fillings were to prevent further dental health 
deterioration. You also say that preventive services are covered. The Plan denied your request. The Plan says 
fillings are not covered services. 
 
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 fillings are not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 5 fillings provided 
on August 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for the lower partial denture (D5214) 
provided on December 31, 2021, by the out of network provider. 
 
You asked the Plan to pay an additional amount for the dental item. You say that you cannot afford to pay this 
bill. The Plan denied your request. The Plan says out of network dentists may bill you for any amount greater 
than what the plan pays. 
 
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 partial denture is listed as covered, 
out of network dentists may bill you for any amount greater than what the plan pays. Therefore, we decided that 
the Plan does not have to pay an additional amount for the lower partial denture (D5214) provided on 
December 31, 2021, by the out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the localized delivery of antimicrobial agents (D4381 x 10) 
provided on December 27, 2021. 
 
You asked the Plan to pay for the dental services. You say that the provider contacted your plan prior to 
receiving services. You say that it was confirmed the services were covered under your plan. The Plan denied 
your request. The Plan says the localized delivery of antimicrobial agents 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the localized delivery of antimicrobial 
agents is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay 
for the localized delivery of antimicrobial agents (D4381 x 10) provided on December 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete maxillary denture (D5110) and complete 
mandibular denture (D5120) provided on November 29, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the complete maxillary denture and complete mandibular denture. You say that 
you would like these services to be covered. The Plan denied your request. The Plan says services performed 
by an OON provider are not covered because your healthcare plan does not have OON benefits. The Plan also 
says that you did not contact the Plan prior to the services being rendered to verify benefits and provider 
eligibility. 
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, you are responsible for 100% of the 
cost for dental services rendered by an OON provider. Therefore, we decided that the Plan does not have to pay 
for the complete maxillary denture (D5110) and complete mandibular denture (D5120) provided on November 
29, 2021 by an out-of-network (OON) provider.  
 
Your complaint about your unhappiness with the Plan and concerns with about the security of your personal 
information 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: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the surgical services rendered on February 24, 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 that procedure code 25290 is not separately payable. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan states that code 25290 is not separately payable because it is a column 
II code to column I code 25609; however, there are no active National Correct Coding Initiative (NCCI) edits 
for this code pair. The Plan has not provided any documentation or Medicare rules to support that code 25290 
is not payable as billed. Therefore, we decided that the Plan has to pay for the surgical services rendered on 
February 24, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an out-of-network provider on 
December 3, 2021. 
 
You asked the Plan to pay for dental services. You say that dentures would not work for you. You say that you 
needed these services because they were medically necessary. The Plan denied your request. The Plan says the 
rendered dental services are not a covered dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for dental 
services provided by an out-of-network provider on December 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the dental services provided from March 11, 2021, 
to March 30, 2021, by the out of network provider. 
 
You asked the Plan to reimburse you for the dental services. You say that you had an accident with the closet 
door that knocked out your front teeth and split your lip. You say that due to the pandemic, you could not get to 
see your regular dentist. You say that you had to rely on another dentist for minor surgery. You also say that 
these services should be covered. 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, the dental services you received out of 
network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
reimburse you for the dental services provided from March 11, 2021, to March 30, 2021, by the out of network 
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis 
(D1110) provided on December 10, 2021. 
 
You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that your dentist advised 
that due to the condition of your teeth, a second cleaning was necessary. You also say that the dentist told you 
that your insurance would cover this cleaning. The Plan denied your request. The Plan says each of these 
services are allowed one time per calendar year. The Plan also says that you have reached this limit for these 
services. 
 
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, you are limited to 1 periodic oral exam 
per and 1 cleaning per year. The record shows that you received a periodic oral evaluation (D0120) and 
prophylaxis (D1110) on June 4, 2021 and your periodic oral exam and cleaning benefits have been exhausted. 
Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and 
prophylaxis (D1110) provided on December 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve five implant supported crowns (D6066 x5). 
 
You asked the Plan to pre-approve the implant supported crowns. 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 five 
implant supported crowns (D6066 x5).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prefabricated abutment (D6056) and implant 
supported crown (D6066) for tooth #30. 
 
You asked the Plan to pre-approve the dental services. You say that these services are necessary. The Plan 
denied your request. The Plan says these services are not covered by your dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
prefabricated abutment (D6056) and implant supported crown (D6066) for tooth #30.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a removable unilateral partial denture (D5282). 
 
You asked the Plan to pre-approve a unilateral partial denture. You say that this service is necessary and should 
be covered. The Plan denied your request. The Plan says this specific kind of denture is not covered by your 
dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the specific type of denture requested 
is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-
approve a removable unilateral partial denture (D5282).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140), extractions (D7210 x 2), 
bone replacement graft (D7953), deep sedation (D9222, D9223 x 2), and therapeutic parenteral drugs (D9612) 
provided from October 12, 2021, to October 19, 2021, by the out of network provider. 
 
You asked the Plan to pay for the dental services. You say that you were never advised the provider was out of 
network. You also say that you are angry because you have to change to providers that do not know your 
history. The Plan denied your request. The Plan says that the services denied 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, 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 limited oral evaluation (D0140), extractions (D7210 x 2), bone replacement graft (D7953), deep sedation 
(D9222, D9223 x 2), and therapeutic parenteral drugs (D9612) provided from October 12, 2021, to October 19, 
2021, by the out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the consultation (D9310) provided on January 12, 2022. 
 
You asked the Plan to pay for the consultation. You say that this was an exam for a treatment plan, and not a 
consultation. The Plan denied your request. The Plan says consult is not covered 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 
consultation (D9310) provided on January 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two resin-based composites (D2330 x2) provided on 
October 26, 2021. 
 
You asked the Plan to pay for the resin-based composites. You say that you feel this procedure was done to 
alleviate the pain and excessive wear on your teeth. You also say that it was not done to enhance your 
appearance or the appearance of your teeth. The Plan denied your request. The Plan says this procedure is not a 
benefit under the dental 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 pay for the two 
resin-based composites (D2330 x2) provided on October 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided by an out-of-
network provider on October 26, 2021. 
 
You asked the Plan to pay for a limited oral evaluation. You say that this visit was for a specific problem. The 
Plan denied your request. The Plan says the benefit limit for D0140 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. The Plan covers two periodic 
oral exams, limited oral evaluation  problem focused, or comprehensive oral exam per calendar year.  
 
We looked at the file and Medicare rules. Evidence was provided to show that two periodic oral evaluations 
were provided on February 24, 2021, and on August 26, 2021. Based on this information, we decided that the 
Plan's rules for coverage of a limited oral evaluation have already been met and exhausted. Therefore, we 
decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided by an out-of-network 
provider on October 26, 2021.