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

 
We decided that the Plan does not have to pay more for resin-based composite fillings on tooth #9 and 11 
(D2331) provided on March 24, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you should only have a $25 copayment. 
The Plan denied your request. The Plan says you are responsible for any charged amount above the Plans cost-
sharing amount when your services are received from an out-of-network provider. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 
 
 
 
 
 You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to pay more for resin-based composite fillings on tooth #9 
and 11 (D2331) provided on March 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for a pontic on tooth #10 (D6241) and retainer 
crowns on tooth #9, 11, and 12 (D6751) provided on October 28, 2021. 
 
You asked the Plan to waive the cost share for a pontic and crowns. You say that you are unemployed, and you 
cannot afford to pay for these services. The Plan denied your request. The Plan says that your annual dental 
benefit maximum amount has been met. 
 
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 have a $1,000 
benefit maximum for covered comprehensive dental services. 
 
The record shows your annual dental benefit maximum amount was met during the processing of this claim. 
Therefore, you are responsible for any amount above the $1,000 maximum amount. A pontic and crowns fall 
within the Dental Services benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the cost share for a pontic on 
tooth #10 (D6241) and retainer crowns on tooth #9, 11, and 12 (D6751) provided on October 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and a periapical x-ray 
(D0220) provided on May 16, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told these services were covered. 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 a limited oral evaluation (D0140) and a periapical x-ray (D0220) provided on May 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for interim dentures (codes D5810 and D5811) you received on 
May 23, 2022. 
 
You asked the Plan to pay for the interim dentures. You say that you thought that you had a $1000 benefit for 
dental services, so you are entitled to that amount. The Plan denied your request. The Plan says these items are 
not covered under your dental benefit and your dental allowance cannot be used for them. 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 interim dentures (codes D5810 and D5811) you received on 
May 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown on tooth #18 (D2740) and core build up on tooth 
#18 (D2950) provided on May 2, 2022. 
 
You asked the Plan to pay for a crown and core build up. You say that you disagree with the denial of dental 
services. The Plan denied your request. The Plan says a crown (D2740) and core build up (D2950) are not 
covered by your routine 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 a crown 
on tooth #18 (D2740) and core build up on tooth #18 (D2950) provided on May 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services billed for date of service March 22, 2022. 
 
You asked the Plan to pay for laboratory services. You say that you have provided medical records to support 
the service billed. The Plan denied your request. The Plan says the available medical records do not support the 
service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. The file shows that the service at issue was a validity test of urine 
specimens utilized for drug testing. Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory 
services billed for date of service March 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive oral evaluation - new or established patient 
(D0150) provided May 26, 2022. 
 
You asked the Plan to pay for the dental services. You say that you switched to a dentist who provides better 
care. You were unaware that there was a frequency limit on this service. 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 October 21, 2020. 
Therefore, we decided that the Plan does not have to pay for comprehensive oral evaluation - new or 
established patient (D0150) provided May 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete 
series x-ray (D0210) provided on March 1, 2022, by the out-of-network dentist. 
 
You asked the Plan to pay for the dental services. You say that you were referred to this dental office. You say 
that 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 dental services you received 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) and complete series x-ray (D0210) provided on March 1, 
2022, by the out-of-network dentist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on 
April 5, 2022. 
 
You asked the Plan to pay for the dental 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 your benefit for the requested item or service was exhausted on date of service February 7, 2022. 
Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) 
provided on April 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional reimbursement for the annual gym membership 
purchased December 11, 2021. 
 
You asked the Plan to provide additional reimbursement for the annual gym membership. You say that you feel 
this should be covered. The Plan denied your request. The Plan says only the membership months in 2021 are 
covered under your 2021 benefit. The remaining months of your membership for 2022 must be submitted for 
reimbursement from your 2022 wellness benefit. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
 
In this case the purchased gym membership covered time in 2021 and 2022. Only the membership time in 2021 
is eligible for reimbursement under the 2021 benefit. The remaining months must be reimbursed under your 2022 benefits.  Therefore, we decided that the Plan does not have to provide additional reimbursement under 
your 2021 wellness benefit for the annual gym membership purchased December 11, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93010 billed for date of service December 3, 
2021. 
 
You asked the Plan to pay for procedure code 93010. Plan denied your request. The Plan says payment for code 
93010 is bundled into payment for code 36556. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 93010 
is a column II code to column I code 36556. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 93010 billed for date of service December 3, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement for the hearing aid (E1399) purchased on
April 21, 2022.

You asked the Plan to issue reimbursement for this item. You say that you are requesting a reconsideration of
the Plan's denial for payment. The Plan denied your request. The Plan says the hearing aid is not payable as it
was purchased from an out-of-network provider.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for
hearing aids only when purchased from the Plan's select hearing aid provider.

We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for
coverage of this item have not been met. Specifically, the hearing aid in this case was not purchased from the
Plan's select hearing aid provider. The Plan contract says that the Plan selects the provider or vendor that will
furnish the covered hearing aid. Coverage is limited to the types and models of hearing aids furnished by the
provider or vendor. Therefore, we decided that the Plan does not have to issue reimbursement for the hearing
aid (E1399) purchased on April 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extractions (D7210 x 5) provided on April 19, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were advised you would only be 
responsible for $271 out of pocket. You say that you should not be responsible for this bill. The Plan denied 
your request. The Plan says the surgical extractions you received are considered dental in nature and are not 
covered. 
 
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 extractions (D7210 x 5) 
provided on April 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide reimbursement for the canal preparation services provided 
on February 3, 2022, described by code D3950, along with a covered root canal service. 
 
You asked the Plan to provide reimbursement for the services described by code D3950. You say that you feel 
that you should be reimbursed for this amount. The Plan denied your request. The Plan says this is not 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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to provide 
reimbursement for the canal preparation services provided on February 3, 2022, described by code D3950, 
along with a covered root canal service.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97010-GP billed for date of service April 29, 
2022. 
 
You asked the Plan to pay for procedure code 97010-GP. You say that you have updated the authorization with 
the provider information, so this should be covered. The Plan denied your request. The Plan says procedure 
code 97010-GP is considered bundled and not separately payable. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 97010-GP has a status indicator of B on the Physician Fee Schedule. This means 
that procedure code 97010-GP is not separately payable. Based on this information, we decided that Medicare 
rules for coverage of procedure code 97010-GP have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure code 97010-GP billed for date of service April 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing in the upper and lower 
right quadrants (D4341) provided on April 27, 2022. 
 
You asked the Plan to pay for periodontal scaling. You say that you were not aware this type of cleaning was 
not covered. The Plan denied your request. The Plan says periodontal scaling and root planing (D4341) is not 
covered by your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, 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 
periodontal scaling and root planing in the upper and lower right quadrants (D4341) provided on April 27, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on May 12, 2022. 
 
You asked the Plan to pay for the dental services. You say that this service should be covered since it was an 
emergency. 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 April 19, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on 
May 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral complete x-ray series (D0210) provided on 
February 10, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were informed by the office that the 
services would be fully 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 requested item or service was exhausted on date of service May 9, 2017. Therefore, 
we decided that the Plan does not have to pay for an intraoral complete x-ray series (D0210) provided on 
February 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for osseous surgery (D4261), bone replacement grafts (D4263, 
D4264), biologic materials (D4265), and guided tissue regeneration (D4266) provided on April 19, 2022. 
 
You asked the Plan to pay for the dental services. You say that these services should be covered. The Plan 
denied your request. The Plan says osseous surgery (D4261), bone replacement grafts (D4263, D4264), 
biologic materials (D4265), and guided tissue regeneration (D4266) are not covered by your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, 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 osseous 
surgery (D4261), bone replacement grafts (D4263, D4264), biologic materials (D4265), and guided tissue 
regeneration (D4266) provided on April 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), a periapical x-ray 
(D0220), and a panoramic x-ray (D0330) provided on June 14, 2022. 
 
You asked the Plan to pay for the dental services. You say that you did not know that your coverage had 
changed. The Plan denied your request. The Plan says the services you received are not covered under your 
supplemental 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 a limited 
oral evaluation (D0140), a periapical x-ray (D0220), and a panoramic x-ray (D0330) provided on June 14, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on 
February 21, 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 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 February 7, 2022. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
provided on February 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral evaluation (D0140), intraoral (D0220), pulp vitality 
tests (D0460), and cone beam (D0364) for tooth #2 provided on May 18, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like for the Plan to pay for the dental 
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 your benefit for the requested item or service was exhausted on date of service March 29, 2022. 
Therefore, we decided that the Plan does not have to pay for the oral evaluation (D0140), intraoral (D0220), 
pulp vitality tests (D0460), and cone beam (D0364) for tooth #2 provided on May 18, 2022.