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

 
We decided that the Plan does not have to pre-approve the guided tissue regeneration (D4266), the bone 
replacement graft (D4263), the surgical placement of implant body (D6010), custom abutment (D6057), and 
the ceramic crown (D6058) for tooth #31. 
 
You asked the Plan to pre-approve the dental services. You say that it is medically necessary to get the dental 
procedures done because the tooth had a root canal. The Plan denied your request. The Plan says the denial of 
authorization for these services is correct, because the guided tissue regeneration, the bone replacement graft, 
the surgical placement of implant body, custom abutment, and the ceramic crown 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 
guided tissue regeneration (D4266), the bone replacement graft (D4263), the surgical placement of implant 
body (D6010), custom abutment (D6057), and the ceramic crown (D6058) for tooth #31.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crowns (D2740) for tooth #12 and #13. 
 
You asked the Plan to pre-approve the dental services. You say that crowns are needed on the teeth to ensure 
long-term success. The Plan denied your request. The Plan says the x-rays show the enrollee's teeth to have 
more than 50% one loss. Which would lead to a questionable long-term prognosis. This tooth does not meet 
clinical requirements for a crown 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. The Plan covers the dental 
services when the services are medically necessary and reasonable.  
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the dental services. Our reviewer says 
that given the records submitted the requested dental services would not be medically reasonable and 
necessary. Our physician reviewer found that the provided x-rays show there is significant periodontal disease 
present on tooth #12 and #13 with more than half the bone missing, leaving less than adequate support for the 
teeth in question. Generally, there should be at least 50% of the supporting bone remaining to provide a 
minimal support for the tooth. If there is insufficient bone to support the teeth to allow for a good long-term 
prognosis, there would be no necessity for crowns as requested. In this case, due to the lack of sufficient bone 
support, there would be no necessity found for the requested crowns as the long-term prognosis would be 
compromised. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve crowns (D2740) for tooth #12 and #13.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for resin-based composites (D2331 and D2392) provided by an 
out-of-network provider on August 9, 2022. 
 
You asked the Plan to pay for the dental services. You say that you exhausted all the in-network providers near 
you. 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 resin-based composites (D2331 and D2392) provided by an out-of-network provider on August 9, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a fixed partial denture sectioning (D9120) and the re-
cemented crown (D2920) provided by an out-of-network provider on July 11, 2022. 
 
You asked the Plan to pay for a fixed partial denture sectioning and the re-cemented crown. You say that you 
paid your out-of-pocket for services rendered by an out-of-network provider. 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 fixed partial denture sectioning (D9120) and the re-cemented crown (D2920) provided by an out-of-network provider 
on July 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for resin-based composite involving four or more surfaces 
(D2335) provided on August 19, 2022. 
 
You asked the Plan to reimburse for dental services. You say that you paid for the services upfront, and you 
expect the service to be covered and receive reimbursement. 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. Resin-based composite 
involving four or more surfaces (D2335) is not covered under the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested resin-based composite 
involving four or more surfaces (D2335) is not among those covered under this benefit. Therefore, we decided 
that the Plan does not have to reimburse for resin-based composite involving four or more surfaces (D2335) 
provided on August 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for general anesthesia provided by an out-of-network provider 
on March 9, 2021. 
 
You asked the Plan to pay for general anesthesia. You say that these services were medically necessary. 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 general 
anesthesia provided by an out-of-network provider on March 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on August 24, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told the provider was in-network and 
you should not be charged. 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, if you choose to see an out-of-network provider you 
may pay more. Therefore, we decided that the Plan does not have to pay for dental services provided on August 
24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical placement of implant body (D6010) and the 
surgical removal of implant body (D6100) for tooth #20, #21, #22, #23, #26, #27, #28, and #29. 
 
You asked the Plan to pre-approve the dental services. You say that it is medically necessary to have implants 
because they help keep your dentures in place. The Plan denied your request. The Plan says the denial of 
authorization for these services is correct, because the surgical placement and removal of implant body 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 pre-approve the 
surgical placement of implant body (D6010) and the surgical removal of implant body (D6100) for tooth #20, 
#21, #22, #23, #26, #27, #28, and #29.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on August 22, 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 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 August 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on July 28, 2022. 
 
You asked the Plan to pay for the dental services. You say that you pay another monthly premium for dental 
services and do not believe you should have to pay this bill. 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 service was exhausted on date of service March 30, 2022. This means you 
would not be eligible for this service again until September 2022. Therefore, we decided that the Plan does not 
have to pay for periodontal maintenance (D4910) provided on July 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power seat elevation system, electronic connection 
between wheelchair controller and two or more power seating system motors, harness for upgrade to 
expandable controller, and expandable controller. 
 
You asked the Plan to pre-approve power seat elevation system, electronic connection between wheelchair 
controller and two or more power seating system motors, harness for upgrade to expandable controller, and 
expandable controller. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan 
says the enrollee does not meet criteria for the requested items. 
 
The Plan must follow Medicare rules. Medicare rules say that wheelchair accessories are only covered for 
certain indications. 
 
We looked at the file and Medicare rules. Review of the file shows that the enrollee has five out of five strength 
in the upper limbs. The enrollee is independent with feeding and grooming. This means the enrollees upper 
limb strength and function are adequate for the enrollee to be able to control the power options using their own 
switches which are included in the allowance of the approved power options. Based on this information, we 
decided that Medicare rules for coverage of power seat elevation system, electronic connection between 
wheelchair controller and two or more power seating system motors, harness for upgrade to expandable 
controller, and expandable controller have not been met. Therefore, we decided that the Plan does not have to 
pre-approve power seat elevation system, electronic connection between wheelchair controller and two or more 
power seating system motors, harness for upgrade to expandable controller, and expandable controller.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a problem-focused oral evaluation (D0140) and intraoral 
periapical radiographic images (D0220, D0230) provided on June 28, 2022. 
 
You asked the Plan to pay for the dental services. You say that you feel that the procedure codes used in billing 
were wrong because at the time of your appointment, you were told the x-rays were covered bitewings. The 
Plan denied your request. The Plan says the claim was processed correctly. The Plan says that there is no 
coverage for the requested services, and you did not contact the Plan prior to the date of service to verify 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 a 
problem-focused oral evaluation (D0140) and intraoral periapical radiographic images (D0220, D0230) 
provided on June 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing (D4342) provided by a 
participating provider June 8, 2022, to July 15, 2022. 
 
You asked the Plan to pay for periodontal scaling and root planing. You say that you go for a cleaning every 
three months. You say that you have been with your dentist for 10 years. 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 
periodontal scaling and root planing (D4342) provided by a participating provider on June 8, 2022, to July 15, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on September 6, 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 September 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a crown (D2740) provided by an out-of-network 
provider on June 1, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you disagree with these charges. The Plan 
denied your request. The Plan says you are responsible for any charged amount above the Plans cost-sharing 
amount when your services are received from an out-of-network provider. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to pay more for a crown (D2740) provided by an out-of-
network provider on June 1, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided on May 25, 2021, to May 31, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for inpatient hospital services. You say that you would like to request reconsideration of the denied claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization is required prior to an out-of-network visit.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for inpatient hospital services provided on May 25, 2021, to May 31, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on August 3, 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 August 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140), the cone beam (D0364), 
and the pulp vitality tests (D0460) for tooth #14 provided on July 12, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are paying extra for the supplemental 
benefit and the dental procedures should be covered. The Plan denied your request. The Plan says your benefit 
for the limited oral evaluation has already been exhausted. The denial of payment for the cone beam and pulp 
vitality tests is correct, because they 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, certain limitations apply. The record 
shows your benefit for the limited oral evaluation was exhausted on the date of service of April 28, 2022. Also, 
the cone beam and the pulp vitality tests are not among covered services under the dental benefit. Therefore, we 
decided that the Plan does not have to pay for the limited oral evaluation (D0140), the cone beam (D0364), and 
the pulp vitality tests (D0460) for tooth #14 provided on July 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewing - single radiographic image (D0270) provided 
on July 15, 2022. 
 
You asked the Plan to pay for the dental services. You say that this x-ray was necessary. The Plan denied your 
request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service February 22, 2022. 
Therefore, we decided that the Plan does not have to pay for the bitewing - single radiographic image (D0270) 
provided on July 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and a complete 
intraoral x-ray series (D0210) provided on April 13, 2022, periodontal scaling and root planing (D4342) 
provided on April 22, 2022, core build up on tooth #6 (D2950) and a crown on tooth #6 (D2740) provided on 
April 27, 2022, and core build up on tooth #13 (D2950) and a crown on tooth #13 (D2740) provided on May 9, 
2022. 
 
You asked the Plan to pay for the dental services. You say that your dentist was told that he was authorized to 
do your dental work. The Plan denied your request. The Plan says the dental services were received from an 
out-of-network provider and are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a comprehensive oral evaluation (D0150) and a complete intraoral x-ray series (D0210) provided on 
April 13, 2022, periodontal scaling and root planing (D4342) provided on April 22, 2022, core build up on 
tooth #6 (D2950) and a crown on tooth #6 (D2740) provided on April 27, 2022, and core build up on tooth #13 
(D2950) and a crown on tooth #13 (D2740) provided on May 9, 2022.