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

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on December 16, 
2021. 
 
You asked the Plan to pay for the dental services. You say that you want the Plan to pay for the service. 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 17, 2021. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on 
December 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for A cone beam CT scan (D0364) provided on April 6, 2022. 
 
You asked the Plan to pay for the cone beam CT scan. 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 were 
non-emergent and prior authorization was not obtained. 
 
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 cone 
beam CT scan (D0364) provided on April 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implant post (D6057) and implant crown (D6061). 
 
You asked the Plan to pre-approve an implant post and crown. You say that you may have a problem with your 
lungs if you do not get the implants done. The Plan denied your request. The Plan says these services are not 
covered under your 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 an 
implant post (D6057) and implant crown (D6061).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on September 7, 2021, billed 
with codes 81302, 81330, 81404, 81405, 81406, 81407, 81408 and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that these services were necessary and are 
supported in the record. The Plan denied your request. The Plan says this claim was not billed in accordance 
with Medicare rules. 
 The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
September 7, 2021, billed with codes 81302, 81330, 81404, 81405, 81406, 81407, 81408 and 81479.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a guided tissue regeneration (D4266). 
 
You asked the Plan to pre-approve the guided tissue regeneration. You say that due to the condition of your 
health you would like these services to be authorized for coverage. 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 
guided tissue regeneration (D4266).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement graft for ridge preservation 
(D7953). 
 
You asked the Plan to pre-approve the bone replacement graft. You say that due to the condition of your health 
you would like these services to be authorized for coverage. 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 
bone replacement graft for ridge preservation (D7953).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental implants (D6013).

You asked the Plan to pre-approve the dental implants. You say that this service is medically necessary. The
Plan denied your request. The Plan says this 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 pre-approve
dental implants (D6013).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extractions of tooth #2, 4, and 5 (D7210) provided on 
June 16, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were in pain, and this was an emergency. 
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 extractions of tooth #2, 4, and 5 (D7210) provided on June 16, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electroencephalogram services provided on December 1, 
2022. 
 
You asked the Plan to pay for the testing services. You say that the tests are requested by the surgeon. The Plan 
denied your request. The Plan says the billed service cannot be verified. 
 
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 95822 is electroencephalogram (EEG); recording in coma 
or sleep only. 
 
 
 We find that CPT code 95822 is not supported in the medical record. Specifically, there is a more 
comprehensive code that describes the intra-operative neuromonitoring service at issue. Based on this 
information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for the electroencephalogram services provided on December 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an apicoectomy (D3421), a retrograde filling (D3430), a 
cyst removal (D7450), and a bone graft (D3428), provided by a participating provider. 
 
You asked the Plan to pre-approve an apicoectomy, a retrograde filling, a cyst removal, and a bone graft. You 
say that these services are medically necessary. The Plan denied your request. The Plan says the requested 
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 pre-approve an 
apicoectomy (D3421), a retrograde filling (D3430), a cyst removal (D7450), and a bone graft (D3428), 
provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the deluxe lens feature (V2702) provided on April 14, 2022. 
 
You asked the Plan to pay for the deluxe lens feature. You say that you had cataract surgery and needed new 
lenses, which should be covered by the Plan. The Plan denied your request. The Plan says the deluxe lens 
feature for polish satin finish is not covered. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers standard frames and lenses as defined by Medicare after cataract surgery. 
 
We looked at the file and the Plan's rules. You received a polish satin finish, which is not a covered benefit. 
Based on this information, we decided that the Plan's rules for coverage of the deluxe lens feature have not 
been met. Therefore, we decided that the Plan does not have to pay for the deluxe lens feature (V2702) 
provided on April 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for a retainer crown on tooth #13 (D6751) and a 
pontic on tooth #12 (D6211) provided on April 14, 2022. 
 
You asked the Plan to waive the cost share for the dental services. You say that you have an issue with the 
crown, and it has not been fixed. The Plan denied your request. The Plan says your annual dental allowance has 
been exhausted. 
 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 this benefit includes 
coverage up to $1,500 for covered preventive and comprehensive dental services. The contract says that you 
are responsible for any amount above the allowance amount. 
 
The record shows your dental allowance was exhausted during the processing of this claim. You have been 
asked to pay a total of $1,850 for the crown and pontic received on April 14, 2022. A crown and pontic fall 
within the Dental Services 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 cost share for a retainer 
crown on tooth #13 (D6751) and a pontic on tooth #12 (D6211) provided on April 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341) 
 
You asked the Plan to pre-approve the periodontal scaling and root planing. 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 you do not meet the requirements for them shown by the x-ray record. 
 
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 
periodontal scaling and root planing (D4341)
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve four pontics (D6240 x4) and two retainer crowns 
(D6750 x2). 
 
You asked the Plan to pre-approve the pontics and retainer crowns. You say that you would like these services 
to be covered for the enrollee. The Plan denied your request. The Plan says these services are not covered 
expenses under the enrollee's dental 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 four 
pontics (D6240 x4) and two retainer crowns (D6750 x2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a retainer crown (D6740) provided by a participating 
provider. 
 
You asked the Plan to pre-approve a retainer crown. You say that the Plan should approve the requested dental 
work. The Plan denied your request. The Plan says the medical criteria has not been met. 
 
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 a retainer 
crown when the services are medically necessary and reasonable.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a retainer crown have not been met. Therefore, we decided that the Plan does not have to pre-
approve a retainer crown (D6740) provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the apicoectomy (D3425) and two retrograde fillings (D3430 
x2) provided on March 21, 2022. 
 
You asked the Plan to pay for the apicoectomy and retrograde fillings. You say that an apicoectomy was the 
only course of action because your tooth already had a root canal, a crack, and a cap. The Plan denied your 
request. The Plan says these procedures are not covered under your dental 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 
apicoectomy (D3425) and two retrograde fillings (D3430 x2) provided on March 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete mandibular denture (D5120) and a complete 
maxillary denture (D5110) provided by a participating provider on October 13, 2021. 
 
You asked the Plan to pay for a complete mandibular denture and a complete maxillary denture. You say that 
you were told that this was covered. The Plan denied your request. The Plan says the rendered dental 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 a 
complete mandibular denture (D5120) and a complete maxillary denture (D5110) provided by a participating 
provider on October 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the periodontal maintenance (D4910) 
provided on June 29, 2022. 
 
You asked the Plan to issue reimbursement for the periodontal maintenance. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services 
provided do not meet criteria for coverage as you do not have any history of periodontal root planning and 
scaling-periodontal surgery or periodontal therapy. 
 
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.   
We looked at the case file and the Plans rules. Based on this information, we decided that the Plan's rules for 
coverage of the periodontal maintenance have not been met. Specifically, the Plan provides coverage of 
periodontal maintenance when following periodontal therapy. The record does not show that you have a history 
of periodontal therapy being provided in this case. Therefore, we decided that the Plan does not have to issue 
reimbursement for the periodontal maintenance (D4910) provided on June 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the retreatment of previous root canal therapy-premolar 
(D3347) provided on May 17, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit under 
your contractual policy. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the service provided is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the retreatment of 
previous root canal therapy-premolar (D3347) provided on May 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a tomographic survey (D0322) provided on April 29, 2022. 
 
You asked the Plan to pay for the dental 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 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 
tomographic survey (D0322) provided on April 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical placement of implant body: endosteal implant 
(D6010), surgical access to an implant body (D6011), custom fabricated abutment (D6057), and abutment 
supported porcelain/ceramic crown (D6058). 
 
You asked the Plan to pre-approve an endosteal implant, surgical access to an implant body, custom fabricated 
abutment, and abutment supported crown. You say that you need the implant because you do not have a tooth. 
The Plan denied your request. The Plan says your plan does not cover these services. 
 
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 
surgical placement of implant body: endosteal implant (D6010), surgical access to an implant body (D6011), 
custom fabricated abutment (D6057), and abutment supported porcelain/ceramic crown (D6058).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve alveoloplasty in conjunction with extractions (D7311). 
 
You asked the Plan to pre-approve alveoloplasty in conjunction with extractions (D7311). You say that when 
extractions are completed without smoothing the area of bone, the patient heals with an irregular alveolus, 
which causes ill-fitting dentures. The Plan denied your request. The Plan says the records indicate that this is 
not a covered benefit under the enrollee's 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 
alveoloplasty in conjunction with extractions (D7311).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on May 3, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were not informed that the exam would be 
denied. 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 3, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on 
May 3, 2022.