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

 
We decided that the Plan does not have to pay for periodontal scaling and root planing - one to three teeth per 
quadrant (D4342) x4 provided on June 29, 2022. 
 
You asked the Plan to pay for dental services. You say that you should not have to pay for this service because 
the Plan is supposed to pay up to $2,000 a year. The Plan denied your request. The Plan says this service is not 
covered under your Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. Periodontal scaling and root 
planing - one to three teeth per quadrant (D4342) is not covered under the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested periodontal scaling and 
root planing - one to three teeth per quadrant (D4342) x4 is not among those covered under this benefit. 
Therefore, we decided that the Plan does not have to pay for periodontal scaling and root planing - one to three 
teeth per quadrant (D4342) x4 provided on June 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral imaging (D0230) and prophylaxis (D1110) 
provided by a participating provider on August 2, 2022. 
 
You asked the Plan to pay for the dental services. You say that you needed these services in order to figure out 
the cause of your pain. 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 D1110 was exhausted on date of service January 5, 2022 and April 5, 2022, and your 
benefit for D0230 was exhausted on August 2, 2022. Therefore, we decided that the Plan does not have to pay 
for intraoral imaging (D0230) and prophylaxis (D1110) provided by a participating provider on August 2, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oral evaluation (D0140) provided on June 20, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the charges. 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, 2022. Therefore, 
we decided that the Plan does not have to pay for an oral evaluation (D0140) provided on June 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal of benign odontogenic cyst or tumor (D7451), 
inhalation of nitrous oxide/analgesia (D9230), intravenous moderate (conscious) sedation/analgesia (codes 
D9239 and D9243), and therapeutic parenteral drug (D9610) provided on April 11, 2022. 
 
You asked the Plan to pay for the removal of benign odontogenic cyst or tumor, inhalation of nitrous 
oxide/analgesia, intravenous moderate (conscious) sedation/analgesia, and therapeutic parenteral drug. You say 
that when the service was provided, you used your dental insurance and tried using your medical insurance, but 
the provider advised they could not take it, so you paid out of pocket. You also say that you were told these 
services would be paid because they were medical services. The Plan denied your request. The Plan says the 
requested items or services are not among those covered under your benefit. 
 
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. The record also shows that you signed an affidavit with the provider acknowledging that you 
could not submit the dental bills to your Medicare plan, and you would be fully responsible for the charges. 
Therefore, we decided that the Plan does not have to pay for the removal of benign odontogenic cyst or tumor 
(D7451), inhalation of nitrous oxide/analgesia (D9230), intravenous moderate (conscious) sedation/analgesia 
(codes D9239 and D9243), and therapeutic parenteral drug (D9610) provided on April 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extraction, erupted tooth requiring removal of bone and/or 
sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210), deep sedation/general 
anesthesia  first 15 minutes (D9222), deep sedation/general anesthesia  each subsequent 15 minute increment 
(D9223), inhalation of nitrous oxide/analgesia, anxiolysis (D9230), therapeutic parenteral drugs, two or more 
administrations, different medications (D9612), alveoloplasty in conjunction with extractions - four or more 
teeth or tooth spaces, per quadrant (D7310), and removal of residual tooth roots (cutting procedure) (D7250) 
provided on December 13, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the dental services. You say that your oral surgeon was changed, and you were 
not aware they were OON. 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 extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including 
elevation of mucoperiosteal flap if indicated (D7210), deep sedation/general anesthesia  first 15 minutes 
(D9222), deep sedation/general anesthesia  each subsequent 15 minute increment (D9223), inhalation of 
nitrous oxide/analgesia, anxiolysis (D9230), therapeutic parenteral drugs, two or more administrations, 
different medications (D9612), alveoloplasty in conjunction with extractions - four or more teeth or tooth 
spaces, per quadrant (D7310), and removal of residual tooth roots (cutting procedure) (D7250) provided on 
December 13, 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 the dental services. 
 
You asked the Plan to pre-approve the dental services. You say that you cannot find an in-network provider 
with the Plan and would like to continue to see the OON provider. The Plan denied your request. The Plan says 
dental services from an out-of-network provider are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  You are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, dental services are not covered under this benefit when received from an out-of-
network provider. Therefore, we decided that the Plan does not have to pre-approve the dental services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for scaling in presence of generalized gingival inflammation 
(D4346) provided by a participating provider on August 17, 2022. 
 
You asked the Plan to pay for scaling in presence of generalized gingival inflammation. You say that you went 
for a regular cleaning. You say that you should not owe anything. The Plan denied your request. The Plan says 
the rendered dental service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for scaling in 
presence of generalized gingival inflammation (D4346) provided by a participating provider on August 17, 
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) 
provided on May 24, 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 this service is not a covered benefit 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 core buildup, 
including any pins when required (D2950) provided on May 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the apicoectomy (D3421 and D3426) for tooth #5. 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denied dental 
service. The Plan denied your request. The Plan says the denial of authorization for this service is correct, 
because apicoectomies 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 pre-approve the 
apicoectomy (D3421 and D3426) for tooth #5.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an upper partial denture (D5213) and a lower partial 
denture (D5214). 
 
You asked the Plan to pre-approve the dental services. You say that you never received partial dentures prior to 
this request. You say you only had impressions done and never received the dentures. 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 code D5213 was exhausted on date of service February 14, 
2020. The record also shows your benefit for the requested code D5214 was exhausted on date of service 
January 6, 2020. Therefore, we decided that the Plan does not have to pre-approve an upper partial denture 
(D5213) and a lower partial denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a periodic oral evaluation (D0120), prophylaxis 
(D1110), and sales tax (D9985), provided by an out-of-network provider on July 27, 2022. 
 
You asked the Plan to pay more for the dental services. You say that these services should be covered. 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. D9985 
is not a covered dental benefit. Therefore, we decided that the Plan does not have to pay more for a periodic 
oral evaluation (D0120), prophylaxis (D1110), and sales tax (D9985), provided by an out-of-network provider 
on July 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral - complete series of radiographic images 
(D0210) provided on June 6, 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 March 15, 2021. 
Therefore, we decided that the Plan does not have to pay for an intraoral - complete series of radiographic 
images (D0210) provided on June 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral exam (D0150) and panoramic x-ray 
(D0330) provided on June 15, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were not aware of the frequency 
limitations. 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 services was exhausted on date of service October 19, 2020. Therefore, 
we decided that the Plan does not have to pay for the comprehensive oral exam (D0150) and panoramic x-ray 
(D0330) provided on June 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on July 7, 2022. 
 
You asked the Plan to pay for the panoramic x-ray. You say that the provider said you needed the panoramic x-
ray (code D0330) done to make sure you have no cancer cells in your jaw. The Plan denied your request. The 
Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service September 19, 2019. 
Therefore, we decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on July 7, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services (D0140, D0220, and D9951) on July 21, 
2022. 
 
You asked the Plan to pay for the dental services (D0140, D0220, and D9951). You say that you would like to 
request reconsideration for payment. 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 dental services (D0140, D0220, and D9951) on July 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on April 20, 2022. 
 
You asked the Plan to pay for the dental services. You say that the enrollee has various disabilities including 
being deaf and nonverbal. The Plan she currently has does not service people with disabilities. 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 dental services provided on April 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on September 15, 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 September 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown - porcelain/ceramic (D2740) provided on May 31, 
2022. 
 
You asked the Plan to pay for the crown. You say that you were not aware that you did not have coverage for 
this service. 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 crown 
- porcelain/ceramic (D2740) provided on May 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the full mouth debridement (D4355) provided on July 12, 
2022. 
 
You asked the Plan to pay for the dental service. You say that the provider is in-network, and the dental service 
should be covered. The Plan denied your request. The Plan says the denial of payment for this service is 
correct, because the full mouth debridement is not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the full 
mouth debridement (D4355) provided on July 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740) provided by a participating provider on 
August 10, 2022. 
 
You asked the Plan to pay for a crown. You say that your old crown fell off. You say that you needed the new 
crown. The Plan denied your request. The Plan says the rendered dental service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. The enrollee does not have supplemental dental benefits. Therefore, 
we decided that the Plan does not have to pay for a crown (D2740) 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 the periodic oral evaluation (D0120), first intraoral periapical 
x-ray (D0220), bitewing x-rays (D0274), panoramic x-ray (D0330), prophylaxis (D1110), and topical 
application of fluoride (D1208) provided on July 26, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the dental services. You say that you cannot afford to pay out of pocket for these 
services because you are on a fixed income. 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 periodic oral evaluation (D0120), first intraoral periapical x-ray (D0220), bitewing x-rays 
(D0274), panoramic x-ray (D0330), prophylaxis (D1110), and topical application of fluoride (D1208) provided 
on July 26, 2022, by an out-of-network (OON) provider.