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

 
We decided that the Plan does not have to pay for a resin-based composite filling on tooth #29 (D2392) 
provided on April 6, 2022. 
 
You asked the Plan to pay for a filling. You say that you disagree with the denial of dental services. The Plan 
denied your request. The Plan says a resin-based composite filling (D2392) is not covered by the Plan's 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 resin-
based composite filling on tooth #29 (D2392) provided on April 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a retainer crown on tooth #19 (D6740) provided on October 
14, 2020. 
 
You asked the Plan to pay for a crown. You say that you disagree with the denial of dental services. The Plan 
denied your request. The Plan says your annual maximum dental allowance has been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows your annual maximum for dental services was met during the processing of this claim. 
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 once the annual maximum has been met. Therefore, we decided that the 
Plan does not have to pay for a retainer crown on tooth #19 (D6740) provided on October 14, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical status does 
not require intensive physician and nursing oversight in an IRF. While you may benefit from additional 
multiple therapies, including physical and occupational therapy, the documentation does not reveal that you 
require or can tolerate this therapy on an intensive IRF level. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the first intraoral periapical x-ray (D0220) and 
palliative (emergency) treatment of dental pain (D9110) provided on March 9, 2022 by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay more for the first intraoral periapical x-ray and palliative (emergency) treatment of 
dental pain. You say that you are appealing this dental bill because you do not feel the coverage is adequate. 
The Plan denied your request. The Plan says you are responsible for any charged amount above the Plan's cost-
sharing amount when your services are received from an OON provider. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  
You have been asked to pay the difference between the OON provider's charges and the Plan's 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 the first intraoral periapical x-ray (D0220) and palliative 
(emergency) treatment of dental pain (D9110) provided on March 9, 2022 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for the fixed partial denture sectioning 
(D9120) provided March 9, 2022. 
 
You asked the Plan to provide additional payment for the fixed partial denture sectioning. You say that this 
service was necessary. The Plan denied your request. The Plan says the service was correctly covered up to 
your dental maximum. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the fixed 
partial denture sectioning up to the $1,000 dental allowance.  
 
We looked at the file, and Medicare rules. The Plan provided documentation showing that at the time of the 
service you had $555 remaining in your dental allowance. This amount was applied to the claim. You have 
been asked to pay the remaining cost above this amount. This means you have been asked to pay the correct 
amount based on your contract with the Plan. Therefore, we decided that the Plan does not have to provide 
additional payment for the fixed partial denture sectioning (D9120) provided March 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete series of intraoral x-rays (D0210) provided on 
March 2, 2022. 
 
You asked the Plan to pay for the complete series of intraoral x-rays. You say that the Plan incorrectly 
informed you that your previous provider no longer accepted Medicare, and the new provider you went to had 
to get a new set of x-rays. 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 the complete series of intraoral x-rays (D0210) 
provided on March 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an opt-out provider on January 
22, 2021, to July 23, 2021. 
 
You asked the Plan to pay for dental services. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says the rendering dentist has opted-out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program until March 28, 2024. Therefore, we decided that the Plan does not have 
to pay for dental services provided by an opt-out provider on January 22, 2021, to July 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the periodic oral evaluation (D0120) and the 
dental cleaning (D1110) provided on February 9, 2022. 
 
You asked the Plan to issue reimbursement for the dental services. You say that you are requesting a 
reconsideration of the Plan's denial 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 dental services from an out-of-network provider. Though the Plan offers a 
dental benefit in excess of Medicare coverage, the services provided in this case are not covered under this 
benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have to 
issue reimbursement for the periodic oral evaluation (D0120) and the dental cleaning (D1110) provided on  
February 9, 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 March 
11, 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 July 26, 2021. Therefore, 
we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on March 
11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on February 
23, 2022, by the out-of-network provider. 
 
You asked the Plan to pay for the dental service. You say that you have received reimbursement for the last 5 
years for out-of-pocket dental expenses. You also say that this is a covered service. The Plan denied your 
request. The Plan says the dental service was received from an out-of-network provider and is 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 periodontal maintenance is 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 periodontal maintenance (D4910) provided on February 23, 2022, by the out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140), and bone replacement 
graft (D7953) provided on March 24, 2022. 
 
You asked the Plan to pay for the dental services. You say that you have just over $1,000 for dental care. You 
also say that you cannot believe that this is not covered. The Plan denied your request. The Plan says 1 limited 
oral evaluation is covered per plan year. The Plan says the frequency limit has been exceeded. The Plan also 
says bone replacement graft is not listed as a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and 1 limited oral evaluation is covered 
per plan year, the frequency limit has been exceeded. The record shows that the Plan paid for a limited oral 
evaluation that you received on March 9, 2022. Additionally, the bone replacement graft is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral 
evaluation (D0140), and bone replacement graft (D7953) provided on March 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone replacement graft (D7953) provided by a participating 
provider on March 18, 2022. 
 
You asked the Plan to pay for a bone replacement graft. You say that you would like the Plan to pay for this. 
The Plan denied your request. The Plan says the rendered dental work 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a bone 
replacement graft (D7953) provided by a participating provider on March 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction of tooth #3, 4, 6, 7, 10, 11, 16, and 31 (D7140) 
provided on December 13, 2021. 
 
You asked the Plan to pay for the extractions. You say that you disagree with the denial of dental services. The 
Plan denied your request. The Plan says your annual dental benefit has been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
The record shows you had met your annual maximum dental benefit. Therefore, we decided that the Plan does 
not have to pay for the extraction of tooth #3, 4, 6, 7, 10, 11, 16, and 31 (D7140) provided on December 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for recement crown on tooth #3 (D2920) provided on February 
24, 2022. 
 
You asked the Plan to pay for the dental services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says recement crown (D2920) 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 recement 
crown on tooth #3 (D2920) provided on February 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay the in network rate for the limited oral evaluation (D0140) 
provided on May 28, 2021. 
 
You asked the Plan to pay the in network rate for the limited oral evaluation. You say that the provider is in 
network. You also say that you did not have an exam done on the date of service in this case. The Plan denied 
your request. The Plan says the limited oral evaluation is not listed as a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the limited oral evaluation is not 
among those covered under this benefit. Additionally, the provided records confirm that an exam was 
performed on the date of service in this case. Therefore, we decided that the Plan does not have to pay the in 
network rate for the limited oral evaluation (D0140) provided on May 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an adjunctive pre-diagnostic test (D0431) provided by a 
participating provider on March 30, 2022. 
 
You asked the Plan to pay for an adjunctive pre-diagnostic test. You say that you would like the Plan to pay for 
these services. The Plan denied your request. The Plan says the denied 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 an 
adjunctive pre-diagnostic test (D0431) provided by a participating provider on March 30, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an x-ray provided on March 7, 2022. 
 
You asked the Plan to waive the copayment for an x-ray. You say that you already paid a copayment for a visit 
with the provider and should not have a separate charge for an x-ray. The Plan denied your request. The Plan 
says the copayment applied was correct. 
 
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 $40 
copayment for Outpatient diagnostic tests.  
 
You have been asked to pay a $40 copayment for an x-ray. An x-ray falls within the Outpatient Diagnostic 
Tests and Therapeutic Services and Supplies 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 copayment 
for an x-ray provided on March 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown (D2740) and core build up (D2950) provided on 
January 27, 2022, by the out-of-network provider. 
 
You asked the Plan to pay for the dental services. You say that your dentist is better than the one that you were 
referred to. The Plan denied your request. The Plan says the services you received are not listed as covered 
dental services. The Plan says that you were advised by a plan representative prior to the date of service that 
crowns were not covered and to utilize in-network providers to receive 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 crown and core build up are not 
among those covered under this benefit, regardless of the provider's network status. Therefore, we decided that 
the Plan does not have to pay for the crown (D2740) and core build up (D2950) provided on January 27, 2022, 
by the out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prophylaxis (D1110) provided on January 5, 2022. 
 
You asked the Plan to pay for prophylaxis. You say that the claims were processed incorrectly. The Plan denied 
your request. The Plan says the annual maximum allowance for dental services has been met. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
The record shows your annual maximum allowance for dental services has been met. 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 once the annual maximum allowance has been met. Therefore, we decided that the Plan does 
not have to pay for prophylaxis (D1110) provided on January 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for complete mandibular dentures (D5120) provided on 
February 22, 2022. 
 
You asked the Plan to pay for the dentures. You say that the denial to cover dentures is discrimination to people 
who wear them. The Plan denied your request. The Plan says complete mandibular dentures (D5120) 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 complete 
mandibular dentures (D5120) provided on February 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for an occlusal adjustment (D9951) provided by a 
participating provider March 14, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you would like the Plan to pay for more of 
this. 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 an occlusal adjustment (D9951) provided by 
a participating provider on March 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complex extraction (D7210) and a bone replacement graft 
(D7953), provided by an out-of-network provider on January 17, 2022. 
 
You asked the Plan to pay for a complex extraction and a bone replacement graft. You say that you needed 
your tooth pulled. The Plan denied your request. The Plan says the rendered dental work 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 a complex 
extraction (D7210) and a bone replacement graft (D7953), provided by an out-of-network provider on January 
17, 2022.