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

 
We decided that the Plan does not have to pre-approve a prefabricated post and core on tooth #8 (D2954) and 
the retreatment of a previous root canal on tooth #8 (D3346). 
 
You asked the Plan to pre-approve the dental services. You say that you disagree with the denial of dental 
services. The Plan denied your request. The Plan says a prefabricated post and core (D2954) and the 
retreatment of a previous root canal (D3346) are not covered by your supplemental 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 pre-approve a 
prefabricated post and core on tooth #8 (D2954) and the retreatment of a previous root canal on tooth #8 
(D3346).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pre-diagnostic test (D0431) and the medicaments (D9630) 
provided on June 10, 2022, and June 13, 2022. 
 
You asked the Plan to pay for the dental services. You say that you thought the appointment was for a routine 
cleaning and did not need the extra dental services. The Plan denied your request. The Plan says the denial of 
payment for these services is correct, because the pre-diagnostic test and the medicaments are 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for pre-
diagnostic test (D0431) and the medicaments (D9630) provided on June 10, 2022, and June 13, 2022.  
 
Your complaint about the extra services provided by the provider is not a valid appeal for medical coverage. 
This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to 
make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation provided on July 
18, 2022. 
 
You asked the Plan to pay for the dental services. You say that the provider should have informed you this 
evaluation would not 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 requested item or service was exhausted on date of service July 11, 2022. Therefore, 
we decided that the Plan does not have to pay for the problem focused limited oral evaluation provided on July 
18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an occlusal mouth guard (D9944) provided on September 7, 
2022. 
 
You asked the Plan to pay for the mouth guard. You say that you would like to be reimbursed for the services 
rendered. 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, 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 an 
occlusal mouth guard (D9944) provided on September 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oral evaluation (D0140) provided on July 26, 2022. 
 
You asked the Plan to pay for the dental services. You say that the dental service should be paid because 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 July 26, 2022. Therefore, 
we decided that the Plan does not have to pay for an oral evaluation (D0140) provided on July 26, 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 April 22, 
2022. 
 
You asked the Plan to pay for the dental service. You say that you were unaware that the provider did not take 
Medicare. 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 the date of service of January 10, 2022. 
Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on 
April 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for periodontal scaling and root planing procedures 
(D4341, D4342) provided by an out-of-network provider on April 28, 2022, and June 20, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you were not made aware that the 
provider does not accept your Medicaid benefits and you cannot afford this bill. 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, even for services listed as a $0 copayment. 
 
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 periodontal scaling and root planing 
procedures (D4341, D4342) provided by an out-of-network provider on April 28, 2022, and June 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sedation (D9222 and D9223) provided on May 10, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told the sedation would not be an out-
of-pocket expense. The Plan denied your request. The Plan says the appeal was partially overturned and your 
annual dental benefit maximum 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 annual dental benefit maximum was exhausted on the date of service of May 10, 2022. On March 
2, 2022, the Plan paid $594 towards the annual dental benefit maximum leaving $406 ($1,000 maximum - $594 
paid) left of the benefit maximum. On April 12, 2022, the Plan paid $21.86 towards the annual dental benefit 
maximum leaving $384.14 ($406 balance of maximum - $21.86 paid) left of the benefit maximum. On May 10, 
2022, the Plan paid the remaining balance of $384.14 left of the benefit maximum. Therefore, we decided that 
the Plan does not have to pay for the sedation (D9222 and D9223) provided on May 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on October 21, 2021. 
 
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 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 pay for the dental 
services on October 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal scaling and root planing - four or more teeth 
per quadrant (D4341) provided on May 5, 2022. 
 
You asked the Plan to pay for the periodontal scaling and root planing. You say that you feel the provider 
should have checked your insurance. The Plan denied your request. The Plan says this service is not covered 
under your 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 
periodontal scaling and root planing - four or more teeth per quadrant (D4341) provided on May 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental therapeutic parenteral drugs (D9612) provided on 
February 9, 2022. 
 
You asked the Plan to pay for the dental therapeutic parenteral drugs. You say that the services should be 
covered as you disagree with the denial. The Plan denied your request. The Plan says the services denied 
correctly as they do not fall within 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 dental 
therapeutic parenteral drugs (D9612) provided on February 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an apicoectomy (D3410), the bone graft (D3428), and 
retrograde filling (D3430) for tooth #24 provided on August 9, 2022. 
 
You asked the Plan to pay for the dental services. You say that the dental procedures utilized are standard 
practice and you thought the Plan would cover 70% of the dental procedures. The Plan denied your request. 
The Plan says the denial of payment for these services is correct, because the apicoectomy, the bone graft, and 
retrograde filling are 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an 
apicoectomy (D3410), the bone graft (D3428), and retrograde filling (D3430) for tooth #24 provided on August 
9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom abutment on tooth #14 (D6057) and an 
implant supported crown on tooth #14 (D6065). 
 
You asked the Plan to pre-approve the dental services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says a custom abutment (D6057) and an implant supported crown (D6065) 
are not covered by the enrollees 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 pre-approve a 
custom abutment on tooth #14 (D6057) and an implant supported crown on tooth #14 (D6065).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the localized delivery of antimicrobial agents (D4381) 
 
You asked the Plan to pre-approve the localized delivery of antimicrobial agents. You say that the services 
should be covered as you disagree with the denial. The Plan denied your request. The Plan says the services 
denied correctly as they do not fall within 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 pre-approve the 
localized delivery of antimicrobial agents (D4381)
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a dental cleaning provided by a participating provider on 
August 10, 2022. 
 
You asked the Plan to pay for the dental services. You say that you need this dental cleaning before you get 
your hip replaced. 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 9, 2022. 
Therefore, we decided that the Plan does not have to pay for a dental cleaning provided by a participating 
provider on August 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), intraoral periapical x-
rays (D0220, D0230), and a series of bitewing x-rays (D0274) rendered by an out-of-network provider on July 
26, 2022. 
 
You asked the Plan to pay for the dental services. You say that the receptionist told you that the office accepted 
your Plan. 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 periodic oral evaluation (D0120), intraoral 
periapical x-rays (D0220, D0230), and a series of bitewing x-rays (D0274) rendered by an out-of-network 
provider on July 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for dental services provided on June 3, 2022, to July 10, 
2022. 
 
You asked the Plan to reimburse for the dental services. You say that the dentist you are assigned to would not 
remove your teeth. 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 reimburse for dental services provided on June 3, 2022, to July 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a crown and core build-up provided by a 
participating provider on March 24, 2022, to March 31, 2022. 
 
You asked the Plan to waive the coinsurance for a crown and core build-up. You say that you are very upset 
that this was denied. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 50% 
coinsurance for Dental Services/Class 2 Basic Services.  
 
You have been asked to pay a 50% coinsurance of the allowed amount for a crown and core build-up. The total 
allowed amount is $978.90. The total amount you are being asked to pay is $489.45 ($978.90 x 50% = 
$489.45). This item/service falls within the Dental Services/Class 2 Basic 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 coinsurance for a crown and core build-up provided by a participating 
provider on March 24, 2022, to March 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an upper partial denture (D5213) provided on July 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told the service would be covered. 
The Plan denied your request. The Plan says the claim was processed correctly. The item at issue is not covered 
by your dental benefit under any normal circumstances. 
 
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 an upper 
partial denture (D5213) provided on July 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crowns (D2740) for tooth #6, #7, #8, #9, #10, and #11. 
 
You asked the Plan to pre-approve the dental services. You say that it is medically necessary for the enrollee to 
get the crowns that are requested. The Plan denied your request. The Plan says the x-rays do not show the tooth 
to have decay or loss due to fracture involving more than 50% of the biting edge of the tooth or tooth surfaces. 
There is not enough missing tooth to necessitate a crown. 
 
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 the dental 
services when the services are medically necessary and reasonable.  
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the dental services. Our reviewer says 
that based on the documentation, there is no medical necessity for the requested crowns. Our physician 
reviewer found that it is clear that the teeth in question has minimal or no restorations previously placed in 
them, and that there is spacing between the teeth and that crowns may be a cosmetic solution to the current 
positioning of the teeth. Although placing crowns on teeth for cosmetic reasons is not unreasonable, it is not 
medically necessary. There is no clear damage to the teeth in question that would require full coverage crowns. 
Crowns may be a cosmetic option but are not medically necessary in this case. 
 
The Plan provides that to meet the criteria for crowns "Permanent anterior teeth must have pathologic 
destruction to the tooth by caries or trauma and must involve four or more surfaces and at least 50% of the 
incisal edge." In this instance none of the teeth exhibit any substantial damage to the incisal surfaces or 
multiple surface restoration or caries. Without substantial damage to the teeth noted, there would be no meeting 
of the Plan criteria for crowns. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve crowns (D2740) for tooth #6, #7, #8, #9, #10, and #11.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a crown (D2740) for tooth #20 provided on July 27, 
2022. 
 
You asked the Plan to pay more for the dental service. You say that you did not know that you had to choose an 
in-network provider. 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 a crown (D2740) for tooth #20 provided on 
July 27, 2022.