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

 
We decided that the Plan does not have to pre-approve a bone replacement graft (D7953), a guided tissue 
regeneration (D4266) and the collection and application of autologous blood concentrate product (D7921). 
 
You asked the Plan to pre-approve a bone replacement graft (D7953), a guided tissue regeneration (D4266) and 
the collection and application of autologous blood concentrate product (D7921). You say that due to a cleft lip 
and missing gum, your roots are hooked shaped not straight down in the gums. You also say that the requested 
provider needs to do after prevention work to avoid infection. The Plan denied your request. The Plan says 
these services are not covered under the member's benefit plan per the EOC. 
 
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 
bone replacement graft (D7953), a guided tissue regeneration (D4266) and the collection and application of 
autologous blood concentrate product (D7921).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), a bone replacement graft 
on tooth #19 (D7953), and guided tissue regeneration on tooth #19 (D4266) provided on March 28, 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 a bone replacement graft (D7953) and guided tissue regeneration 
(D4266) are not covered by your dental benefits. The Plan also says that your benefit for a limited oral 
evaluation 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, a bone replacement graft and guided 
tissue regeneration are not among those covered under this benefit. The record shows your benefit for a limited 
oral evaluation was exhausted on date of service January 18, 2022. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140), a bone replacement graft on tooth #19 (D7953), and 
guided tissue regeneration on tooth #19 (D4266) provided on March 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic (D6240) and three retainer crowns (D6750 x3). 
 
You asked the Plan to pre-approve the pontic and retainer crowns. You say that your removable mandibular 
prosthesis is broken, and you have lost it. The Plan denied your request. The Plan says according to your dental 
history, you received a mandibular partial denture (D5214) on January 13, 2021, and your 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the Plan's original decision does not 
apply, as the requested items or services are not among those covered under this benefit. Only fixed prosthetic 
repairs are covered under your plan. A new bridge is not listed as a covered service.  
 
 
  
 
 
Therefore, we decided that the Plan does not have to pre-approve a pontic (D6240) and three retainer crowns 
(D6750 x3).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an immediate mandibular partial denture (D5222), 
adjustment to a maxillary partial denture (D5421), repair a broken complete maxillary denture base (D5512), 
and eight simple extractions (D7140 x8) to be rendered by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the dental services. You say that you have an established dentist that is not 
in-network, and you are not willing to change practices. You also say your immediate concern is a cracked 
upper denture that needs to be replaced. 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, 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 pre-approve an 
immediate mandibular partial denture (D5222), adjustment to a maxillary partial denture (D5421), repair a 
broken complete maxillary denture base (D5512), and eight simple extractions (D7140 x8) to be rendered 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 treatment of root canal obstruction (D3331) 
provided by a participating provider. 
 
You asked the Plan to pre-approve the treatment of root canal obstruction. You say that you would like the Plan 
to approve these services. The Plan denied your request. The Plan says the requested 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 pre-approve the 
treatment of root canal obstruction (D3331) provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement graft (D4263) and guided tissue 
regeneration (D4266). 
 
You asked the Plan to pre-approve a bone replacement graft and guided tissue regeneration. You say that 
treatment is needed because you have bacteria in your gums. You also say that you do not have money to cover 
the treatment. 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 pre-approve a 
bone replacement graft (D4263) and guided tissue regeneration (D4266).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) and surgical 
extractions (D7210) to be rendered by an oral surgeon. 
 
You asked the Plan to pre-approve the comprehensive oral evaluation and surgical extractions. You say that 
you are in pain and need to have teeth pulled. The Plan denied your request. The Plan says your contract with 
the Plan only provides coverage for dental services when they are performed by a participating general dentist. 
The Plan also says that dental services performed by an oral surgeon are 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 
covered when they are received by anyone other than a participating general dentist. Therefore, we decided that 
the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) and surgical extractions 
(D7210) to be rendered by an oral surgeon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and scaling in 
presence of generalized moderate or severe gingival inflammation (D4346) provided by a participating 
provider on May 16, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says your benefit for D0150 has already been exhausted. D4346 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, certain limitations apply. The record 
shows your benefit for D0150 was exhausted on date of service November 4, 2020. D4346 is not a covered dental benefit. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation 
(D0150) and scaling in presence of generalized moderate or severe gingival inflammation (D4346) provided by 
a participating provider on May 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two removals of torus mandibularis (D7473 x2). 
 
You asked the Plan to pre-approve the removals of torus mandibularis. You say that the enrollee needs their 
tori to be removed for placement of their dentures. The Plan denied your request. The Plan says this service is 
not covered under the enrollee's 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 pre-approve two 
removals of torus mandibularis (D7473 x2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction of tooth #18 (D7210) and a dental procedure 
(99999) provided on February 23, 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 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 extraction of tooth #18 (D7210) and a dental procedure (99999) provided on February 23, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service March 1, 
2022. 
 
You asked the Plan to pay for procedure code 99053. You say that this claim was coded correctly. The Plan 
denied your request. The Plan says procedure code 99053 is considered bundled and not separately payable. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99053 billed for date of service March 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implant /abutment supported removable denture for 
edentulous arch - mandibular (D6111) provided by an out-of-network provider. 
 
You asked the Plan to pre-approve an implant /abutment supported removable denture for edentulous arch - 
mandibular. You say that these services are medically necessary. The Plan denied your request. The Plan says 
the requested dental service is not a covered dental 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 pre-approve an 
implant /abutment supported removable denture for edentulous arch - mandibular (D6111) provided by an out-
of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on May 
12, 2022. 
 
You asked the Plan to pay for the dental services. You say that the evaluation should 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 January 15, 2021. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
provided on May 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive periodontal oral evaluation (D0180), 
bitewing radiographic images (D0274), and a panoramic radiographic image (D0330) provided on May 10, 
2022. 
 
You asked the Plan to pay for the dental services. You say that you were not aware that the services would not 
be covered. The Plan denied your request. The Plan says your benefits for the bitewing radiographic images 
and the panoramic radiographic image have already been exhausted. The comprehensive periodontal oral 
evaluation 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, certain limitations apply. The record 
shows your benefit for the bitewing radiographic image was exhausted on date of service April 11, 2022, and 
your benefit for the panoramic radiographic image was exhausted on date of service October 9, 2020. 
Additionally, the comprehensive periodontal oral evaluation is not a covered benefit. Therefore, we decided 
that the Plan does not have to pay for a comprehensive periodontal oral evaluation (D0180), bitewing 
radiographic images (D0274), and a panoramic radiographic image (D0330) provided on May 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for crown repair services (D2980) provided on February 17, 2022.

You asked the Plan to pay for the crown repair services. 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 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 crown repair services (D2980) provided on February 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mandibular partial denture (D5214). 
 
You asked the Plan to pre-approve a mandibular partial denture. You say that you need this bottom denture but 
cannot cover the cost yourself. 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 pre-approve a mandibular partial denture (D5214).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on August 25, 2021.

You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the claim was billed with the incorrect date of service.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

We find that payment for CPT code 0037U is not supported in the medical record. Specifically, the claim must be billed with the date the specimen was collected. The records show that the specimen was collected on April 20, 2021. As such, the claim was billed with the incorrect date of service. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on August 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endodontic therapy (D3330) and surgical extraction 
(D7210). 
 
You asked the Plan to pre-approve the endodontic therapy and surgical extraction. You say that you feel these 
services should be covered. The Plan denied your request. The Plan says these services are not covered under 
your dental plan. The Plan also says that these services are listed as covered under the Plan's dental rider, but 
you are not enrolled in this rider. 
 
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 
endodontic therapy (D3330) and surgical extraction (D7210).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the one retainer crown (D6740) provided on March 10, 
2022. 
 
You asked the Plan to pay for the additional retainer crown. You say that you counted on your insurance 
covering the majority of your dental work, but that did not happen. The Plan denied your request. The Plan 
says your annual maximum 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 annual maximum benefit was exhausted on date of service May 5, 2022. Therefore, we decided 
that the Plan does not have to pay more for the one retainer crown (D6740) provided on March 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scalings and root planings (D4342) of the 
lower left quadrant and lower right quadrant. 
 
You asked the Plan to pre-approve the scalings and planings. 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 June 25, 2020. Therefore, 
we decided that the Plan does not have to pre-approve periodontal scalings and root planings (D4342) of the 
lower left quadrant and lower right quadrant.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental surgery (41899, D4261, D4260) provided on March 
25, 2021. 
 
You asked the Plan to pay for the dental surgery. 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 
surgery (41899, D4261, D4260) provided on March 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an autogenous connective tissue graft procedure 
(D4273). 
 
You asked the Plan to pre-approve an autogenous connective tissue graft procedure. You say that you were 
informed that periodontal services are covered under your plan, but the particular surgery is not. You also say 
that this surgery was always covered under your previous dental plans. 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. 
 
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 
autogenous connective tissue graft procedure (D4273).