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

 
We decided that the Plan does not have to pay for the top fluoride varnish (D1206) provided on August 9, 
2022. 
 
You asked the Plan to pay for the top fluoride varnish (D1206). You say that you were told the service was 
covered. 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 top fluoride varnish (D1206) was 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
top fluoride varnish (D1206) provided on August 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an overdenture (D5865) 
 
You asked the Plan to pre-approve the overdenture. 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 an 
overdenture (D5865)
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 50715 billed for date of service March 2, 
2022. 
 You asked the Plan to pay for procedure code 50715. You did not provide a specific argument with your appeal 
request. The Plan denied your request. The Plan says payment for code 50715 is bundled into payment for code 
49204. 
 
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 50715 
is a column II code to column I code 49204. 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 50715 billed for date of service March 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown - porcelain fused to high noble metal tooth #18 
(D2750) provided on July 11, 2022. 
 
You asked the Plan to pay for the crown - porcelain fused to high noble metal tooth #18 (D2750). The Plan 
denied your request. The Plan says this service is not covered under the benefit package. 
 
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 - 
porcelain fused to high noble metal tooth #18 (D2750) provided on July 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and prophylaxis 
(D1110) provided on July 19, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with denial of dental services. The 
Plan denied your request. The Plan says your benefit for the requested items or services has already been 
exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested items or services was exhausted on date of service January 26, 2022. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and 
prophylaxis (D1110) provided on July 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the complete upper denture (D5110) and the complete 
lower denture (D5120). 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denied 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 the date of service of August 12, 2021. 
Therefore, we decided that the Plan does not have to pre-approve the complete upper denture (D5110) and the 
complete lower denture (D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral exam (D0140) provided on August 9, 2022. 
 
You asked the Plan to pay for the limited oral exam. You say that you feel the dental office should resubmit the 
claim as a comprehensive exam. 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 
limited oral exam (D0140) provided on August 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a facility house call (D9410), caries risk assessment (D0602), 
an adjunctive pre-diagnostic test (D0431), oral hygiene instructions (D1330), and a 2D oral/facial photographic 
image (D0350) provided on June 24, 2022. 
 
You asked the Plan to pay for the dental services. You say that you live in a senior's facility and the dentist was 
at the facility to provide "free" dental care. The Plan denied your request. The Plan says a facility house call 
(D9410), caries risk assessment (D0602), an adjunctive pre-diagnostic test (D0431), oral hygiene instructions (D1330), and a 2D oral/facial photographic image (D0350) 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 pay for a facility 
house call (D9410), caries risk assessment (D0602), an adjunctive pre-diagnostic test (D0431), oral hygiene 
instructions (D1330), and a 2D oral/facial photographic image (D0350) provided on June 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardioversion rendered on April 25, 2022. 
 
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 procedure code 92960 is not supported. 
 
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, the CPT Code Manual definition of code 92960 is cardioversion, elective, electrical conversion of 
arrhythmia; external. 
 
We find that CPT code 92960 is not supported in the medical record. Specifically, there is no documentation of 
elective external cardioversion with electrical conversion of arrhythmia. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does 
not have to pay for the cardioversion rendered on April 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on June 2, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the services are not covered 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 dental 
services on June 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two periodontal scalings and root planings (D4341 x2) 
and local anesthesia (D9210) provided on August 18, 2022. 
 
You asked the Plan to pay for the scalings and planings and local anesthesia. You say that these procedures 
were required, and you would like them to be covered under your dental plan. The Plan denied your request. 
The Plan says these services are 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 pay for the two 
periodontal scalings and root planings (D4341 x2) and local anesthesia (D9210) provided on August 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the porcelain/ceramic crowns (D2740) provided on June 21, 
2022. 
 
You asked the Plan to pay for the porcelain/ceramic crowns (D2740). You say that you and your dentist did not 
have sufficient information from the Plan to determine the course of action in order to fix your teeth. The Plan 
denied your request. The Plan says the services were not covered 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 porcelain/ceramic crowns (D2740) 
is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
porcelain/ceramic crowns (D2740) provided on June 21, 2022.  
 
Your complaint about the Plans payment and reimbursement program 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 surgical placement of the endosteal implant (D6010) and 
the extraction (D7140) provided by an out-of-network provider on April 20, 2022. 
 
You asked the Plan to pay for the dental services. You say that you had to go out-of-network because the Plan 
could not assist you with the procedure. 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 surgical placement of the endosteal implant (D6010) 
and the extraction (D7140) are not covered under this benefit when received from an out-of-network provider. 
The record shows the provider was out-of-network. Therefore, we decided that the Plan does not have to pay 
for the surgical placement of the endosteal implant (D6010) and the extraction (D7140) provided by an out-of-
network provider on April 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic parenteral drug (D9610). 
 
You asked the Plan to pre-approve a therapeutic parenteral drug. You say that the enrollee's infected teeth need 
to be extracted with intravenous sedation. You also say that an incision and drainage will be necessary if the 
large infection does not drain from the extraction socket, and an injection of Dexamethasone will be given for 
post-operative pain and swelling. The Plan denied your request. The Plan says this service is 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 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 
therapeutic parenteral drug (D9610).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for adjunctive pre-diagnostic test that aids in detection of 
mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy 
procedures tooth #'s 1, 32 (D0431), and gingival irrigation  per quadrant tooth #'s 25, 32 (D4921) provided on 
June 20, 2022. 
 You asked the Plan to pay for adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities 
including premalignant and malignant lesions, not to include cytology or biopsy procedures tooth #'s 1, 32 
(D0431), periodontal maintenance tooth #'s 1, 32 (D4910), and gingival irrigation  per quadrant tooth #'s 25, 
32 (D4921). You say that you have a history of periodontal maintenance 3-4 times a year. The Plan denied your 
request. The Plan says these services are not covered under the benefit package. 
 
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 
adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities including premalignant and 
malignant lesions, not to include cytology or biopsy procedures tooth #'s 1, 32 (D0431), and gingival irrigation 
 per quadrant tooth #'s 25, 32 (D4921).  The plan agreed to pay for periodontal maintenance tooth #'s 1, 32 
(D4910) provided on June 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a topical application of fluoride varnish (D1206) provided by 
a participating provider on July 15, 2022. 
 
You asked the Plan to pay for a topical application of fluoride varnish. You say that you believe that this was 
coded incorrectly. 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 rendering dentist verified that the correct code was applied. 
Therefore, we decided that the Plan does not have to pay for a topical application of fluoride varnish (D1206) 
provided by a participating provider on July 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pontic (D6245) provided by a participating provider on 
March 23, 2022. 
 
You asked the Plan to pay for a pontic. You say that you have coverage for two crowns a year. The Plan denied 
your request. The Plan says these services have been correctly denied. 
 
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 pontic 
(D6245) provided by a participating provider on March 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive periodontal evaluation - new or established 
patient (D0180) provided on July 5, 2022. 
 
You asked the Plan to pay for the comprehensive periodontal evaluation - new or established patient (D0180). 
You say that it was your understanding that the Plan allows you to visit an out-of-network provider for 
preventable care and to receive a partial payment. The Plan denied your request. The Plan says this service is 
not covered under the benefit package. 
 
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 
comprehensive periodontal evaluation - new or established patient (D0180) provided on July 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete series of radiographic images (D0210) provided 
by a participating provider on August 31, 2022. 
 
You asked the Plan to pay for the dental services. You say that the second dentist was able to treat you. 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 January 20, 2022. Therefore, we decided that the Plan does not have to pay for a complete series of radiographic images (D0210) 
provided by a participating provider on August 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oral/facial photographic image (D0350) provided on June 27, 
2022. 
 
You asked the Plan to pay for oral/facial photographic image (D0350). You say that you called the provider 
first to make sure they approved of your plan. You also say that the provider told you not to worry, that they 
could fix that if it was wrong. The Plan denied your request. The Plan says this service is not covered under the 
member's contract 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 oral/facial 
photographic image (D0350) provided on June 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on July 14, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says 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 on July 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gingivectomy or gingivoplasty - one to three contiguous 
teeth or tooth bounded spaces per quadrant (D4211) provided on May 4, 2022. 
 
You asked the Plan to pay for the gingivectomy or gingivoplasty - one to three contiguous teeth or tooth 
bounded spaces per quadrant (D4211). You say that the services were reasonable and necessary and want them 
covered. The Plan denied your request. The Plan says this service is not covered under the benefit package. 
 
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 
gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quadrant (D4211) 
provided on May 4, 2022.