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

 
We decided that the Plan does not have to pre-approve detailed and extensive treatment planning (D9450) and 
adjunctive procedure (D9999). 
 
You asked the Plan to pre-approve a detailed and extensive treatment planning and adjunctive procedure. You 
say that no treatment plan has been developed and the Plan's determination is premature and unwarranted at 
this point in time. The Plan denied your request. The Plan says orthodontic treatment 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 
detailed and extensive treatment planning (D9450) and adjunctive procedure (D9999).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the simple extractions (D7140 x 6), surgical extraction 
(D7210), removal of residual tooth roots (D7250 x 4), complete upper denture (D5110), and full mouth 
debridement (D4355) provided from January 11, 2022, to February 3, 2022. 
 
You asked the Plan to pay for the dental services. You say that a plan representative advised that 2 extractions 
would be covered in 2022. You also say that if nothing is paid you will never buy this insurance again. The 
Plan denied your request. The Plan says the services you received are not listed as covered. The Plan says that 
they are not liable for information given to you by an outside broker as they are not employed directly by the 
plan. The Plan also says that the claim processed correctly. 
 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 extractions, removal of residual 
tooth roots, denture, and full mouth debridement are not among those covered under this benefit. Therefore, we 
decided that the Plan does not have to pay for the simple extractions (D7140 x 6), surgical extraction (D7210), 
removal of residual tooth roots (D7250 x 4), complete upper denture (D5110), and full mouth debridement 
(D4355) provided from January 11, 2022, to February 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diagnostic consultation (D9310), local anesthesia 
(D9215) and surgical extraction (D7210) provided on October 25, 2021. 
 
You asked the Plan to pay for dental services. You say that these services were necessary, and you should be 
reimbursed for this treatment. You say you did not understand that this provider was an opt out provider. The 
Plan denied your request. The Plan says the provider in this case does not participate in Original Medicare. 
Based on your contract, this means these services are not eligible for payment or reimbursement. In addition, 
the documentation submitted by the provider's office shows that you have signed a contract with the provider 
on the date in question which acknowledges that you are responsible for payment of these services, and they 
are not covered by Medicare. 
 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 dental 
services when the services are performed by a licensed dental provider who accepts Medicare patients in the 
United States.  
 
We looked at the file and the Plan's rules. The provider in this case does not accept Medicare payment for 
services and has opted out of Medicare. Based on this information, we decided that the Plan's rules for 
coverage of dental services have not been met. Therefore, we decided that the Plan does not have to pay for the 
diagnostic consultation (D9310), local anesthesia (D9215) and surgical extraction (D7210) provided on 
October 25, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion device.

You asked the Plan to pre-approve a Vertiflex Superion device. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

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 a Vertiflex Superion device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the vertiflex device is experimental. More research is needed.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Vertiflex Superion device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Superion device.
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), topical 
application of fluoride varnish (D1206), and comprehensive oral evaluation (D0150) provided on January 27, 
2022. 
 
You asked the Plan to pay for the complete series of intraoral x-rays, topical application of fluoride varnish, 
and comprehensive oral evaluation. You say that this examination is completed as standard practice by dentists 
for new patients, of which you are at the office you were treated by. You also say that through no fault of your 
own, the Plan made you change to a new dental practice due to their non-coverage with your previous dentist. 
The Plan denied your request. The Plan says the complete series of intraoral x-rays and topical application of 
fluoride varnish are not covered expenses under your dental plan. The Plan also says that your comprehensive 
oral evaluation benefit has been satisfied and the frequency limitation has been exceeded.  
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, complete series of intraoral x-rays 
(D0210) and topical application of fluoride varnish (D1206) are not among those covered under this benefit. 
The contract says that comprehensive oral evaluation (D0150) is limited to 1 procedure code every 3 calendar 
years. The record shows that you received a comprehensive oral evaluation (D0150) on January 22, 2020 and 
your comprehensive oral evaluation (D0150) benefit has been exhausted. Therefore, we decided that the Plan 
does not have to pay for the complete series of intraoral x-rays (D0210), topical application of fluoride varnish 
(D1206), and comprehensive oral evaluation (D0150) provided on January 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 2D oral photographic images (D0350 x 4) provided on 
January 13, 2022. 
 
You asked the Plan to pay for the 2D photographic images. You say that you were not given any information 
on how much the services would cost or what the plan would cover. You also say that you will not pay such an 
exorbitant fee if asked to do so. The Plan denied your request. The Plan says 2D photographic image 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the 2D photographic images are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 2D 
oral photographic images (D0350 x 4) provided on January 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the immediate denture - maxillary (D5130) provided October 
6, 2021. 
 
You asked the Plan to pay for the upper immediate denture. You say that this service was necessary. The Plan 
denied your request. The Plan says this service is not covered under your benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
immediate denture - maxillary (D5130) provided October 6, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 4 additional home health physical therapy (PT) visits. 
 You asked the Plan to pre-approve 4 additional home health PT visits. You say that the services are medically 
necessary. The Plan denied your request. The Plan says 4 additional home health visits are not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 4 additional home health PT visits. Our 
reviewer says that 4 additional visits are not medically necessary. Our physician reviewer found the provided 
documentation does not support that the enrollee requires additional skilled rehab services to provide treatment 
that is medically necessary. The reviewer found that the enrollee does not require additional skilled rehab 
services to effectively provide treatment, care, and/or services in order to improve their condition, perform a 
maintenance program to maintain their condition and/or prevent deterioration. The reviewer also found that the 
enrollee has been medically stable without any recent exacerbations of chronic medical problems or 
hospitalizations. Therefore, the reviewer found that the additional 4 home health visits are not medically 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 4 additional home health PT visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 4 additional home health physical therapy (PT) visits.
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 the Plan paid for a partial in 
November 2021 which you did not receive because the dentist could not adjust it to stay in your mouth. The 
Plan denied your request. The Plan says your benefits for this service have been satisfied and the frequency 
limitation has been exceeded. 
 
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, you are limited to 1 upper and/or 1 
lower partial denture every 5 calendar years. The record shows that you received a mandibular partial denture 
(D5214) on October 14, 2021 and your mandibular partial denture benefit has been exhausted. Therefore, we 
decided that the Plan does not have to pre-approve a mandibular partial denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown (D2750) provided on February 17, 2022. 
 
You asked the Plan to pay for the crown. You say that you desperately need this crown approved for coverage. 
The Plan denied your request. The Plan says the crown benefit has a limit to two in a calendar year. The Plan 
also says that your history plus this request has gone over this limit. 
 
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, you are limited to two crowns per 
calendar year. The record shows that you received two crowns (D2740) on January 28, 2022 and your crowns 
benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the crown (D2750) 
provided on February 17, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the surgical extraction (D7210) provided on February 15, 2022. 
 
You asked the Plan to pay for the surgical extraction. You say that you would like this extraction to be fully 
covered. The Plan denied your request. The Plan says that oral surgery services are not covered. The Plan also 
says that the provider billed a surgical extraction, which is considered oral surgery, and not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not provide a copy of the applicable 2022 Evidence of Coverage 
for this case. Without this information we cannot determine that the Plan's coverage rules support the denial of 
payment in this case, or that the enrollee has been adequately notified of the Plan's coverage rules and benefits. 
Consequently, the Plan has not substantiated their denial of payment in this case. Therefore, we decided that 
the Plan has to pay for the surgical extraction (D7210) provided on February 15, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis 
(D1110) provided on September 13, 2021 by a Medicare opt out provider. 
 
You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that in March of 2021 you 
asked the provider's office to file your claim, and you also requested the same when you went to the 
appointment in September. You also say that you would like to be reimbursed for these services. The Plan 
denied your request. The Plan says these services were rendered by a provider who chose not to receive 
Medicare funds. 
 
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 a provider who has opted out of Medicare. Therefore, we decided that the 
Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis (D1110) provided on 
September 13, 2021 by a Medicare opt out provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay and additional amount for the partial upper denture (D5213) and 
partial lower denture (D5214) provided on February 10, 2022. 
 
You asked the Plan to pay and additional amount for the dental items. You say that you were told by a plan 
representative in November 2021 that you would not have to pay anything for the partials. You say that The 
Plan denied your request. The Plan says no additional payment will be made. 
 
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 and partial dentures are listed as covered, there is a 70% coinsurance when received in network. This is a contractual obligation you agreed to 
when you enrolled in the Plans dental coverage. Therefore, we decided that the Plan does not have to pay and 
additional amount for the partial upper denture (D5213) and partial lower denture (D5214) provided on 
February 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), panoramic x-ray 
(D0330), prophylaxis (D1110), and topical application of fluoride varnish (D1206) provided on December 21, 
2021 by a Medicare opt out provider. 
 
You asked the Plan to pay for the periodic oral evaluation, panoramic x-ray, prophylaxis, and topical 
application of fluoride varnish. You say that you have been going to this provider for a number of years and the 
Plan has paid for the services. The Plan denied your request. The Plan says you received these services from a 
provider who chose not to receive Medicare funds. 
 
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 
periodic oral evaluation (D0120), panoramic x-ray (D0330), prophylaxis (D1110), and topical application of 
fluoride varnish (D1206) provided on December 21, 2021 by a Medicare opt out provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided on December 14, 2021. 
 
You asked the Plan to pay for the dental services. You say that it was not disclosed to you that she dropped her 
license with Medicare, and this was to be reimbursed like all other claims. The Plan denied your request. The 
Plan says payment cannot be made for services performed by providers who have opted out of the Medicare. 
 
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, dental services performed by a 
provider that has opted out of Medicare are not among those covered under this benefit. Therefore, we decided 
that the Plan does not have to pay for the dental services provided on December 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation with a periodontist. 
 
You asked the Plan to pre-approve the consultation. You say that you need to see a periodontist for tooth #8, 
and disagree with the Plan's decision. The Plan denied your request. The Plan says dental services are only 
covered when they are performed by a participating general dentist. The Plan also says that dental services 
performed by a periodontist 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 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
consultation with a periodontist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the endodontic procedure (D3999) and therapeutic parenteral 
drug (D9610) provided on February 7, 2022. 
 
You asked the Plan to pay for the endodontic procedure and therapeutic parenteral drug. You say that you paid 
$145 for these services which were denied by the Plan. You also say that you need to undergo other procedures 
and depend on the support of the Plan. The Plan denied your request. The Plan says these 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 
endodontic procedure (D3999) and therapeutic parenteral drug (D9610) provided on February 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established 
patient (D0150) and intraoral - complete series of radiographic images (D0210) provided January 18, 2022. 
 
You asked the Plan to pay for the comprehensive oral exam and complete series of intraoral x-rays. You say 
that you felt it was in your best interest to go to another dentist who could take care of all your dental needs in a 
more professional manner. The Plan denied your request. The Plan says you have exceeded the frequency 
limits for these services. 
 
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 
comprehensive oral exam and complete series of intraoral x-rays once every three plan years.  
 
We looked at the file and Medicare rules. The Plan provided documentation showing that a comprehensive oral exam and complete series of x-rays were previously covered on September 1, 2021. Based on this 
information, we decided that the Plan's frequency limits for coverage of the comprehensive oral exam and 
complete series of intraoral x-rays have been exceeded. Therefore, we decided that the Plan does not have to 
pay for the comprehensive oral evaluation - new or established patient (D0150) and intraoral - complete series 
of radiographic images (D0210) provided January 18, 2022.