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

 
We decided that the Plan does not have to pay for periodontal maintenance on tooth #4 (D4910) and intraoral 
x-ray (D0220) provided on October 19, 2021. 
 
You asked the Plan to pay for periodontal maintenance and x-rays. You say that you have been seen this 
provider in the past and have had no issues with services being covered. The Plan denied your request. The 
Plan says this provider has opted out of Medicare and is not eligible for payment. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
We confirmed that the provider has opted out of Medicare and is not eligible for payment. The services at issue 
in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the 
Medicare program. Therefore, we decided that the Plan does not have to pay for periodontal maintenance on 
tooth #4 (D4910) and intraoral x-ray (D0220) provided on October 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone replacement graft, retained natural tooth, first site 
in quadrant (D4263x4), guided tissue regeneration, resorbable barrier, per site (D4266x4) and an occlusal guard 
for teeth grinding (D9944). 
 
You asked the Plan to pre-approve dental services. You say that the surgery that is being requested is not 
cosmetic at all and that there is pressing medical necessity that can be verified by your dental provider and your 
primary care physician through clinical documentation. The Plan denied your request. The Plan says the 
requested services are not listed and therefore excluded from coverage. 
 
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 bone 
replacement graft, retained natural tooth, first site in quadrant (D4263x4), guided tissue regeneration, 
resorbable barrier, per site (D4266x4) and an occlusal guard for teeth grinding (D9944).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite filling on February 4, 2022. 
 
You asked the Plan to pay for a resin-based composite filling. You say that you feel the services should be 
covered because you weren't aware that you had to tell them what type of filling material to use. The Plan 
denied your request. The Plan says Based on the information received, it was determined that the claim 
processed correctly in accordance with your dental plan benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a resin-
based composite filling on February 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), prophylaxis 
(D1110), and full mouth x-rays (D0210) provided on January 10, 2022. 
 
You asked the Plan to pay for an evaluation, prophylaxis, and x-rays. You say that the dental services were 
medically necessary. The Plan denied your request. The Plan says the services are not covered when seen by a 
non-participating 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. 
 
The record shows you received 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 provided by a non-participating provider. Therefore, we decided that the Plan does not have to 
pay for a comprehensive oral evaluation (D0150), prophylaxis (D1110), and full mouth x-rays (D0210) 
provided on January 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup (dental code D2950) the guided tissue 
regeneration (dental code D4266) or waive the coinsurance for the crown (dental code D6740), the extraction 
(dental code D7210), the pontic (dental code D6245) for tooth #18, #19, and #20 provided on January 25, 2022. 
 
You asked the Plan to pay for the core buildup, the crown, the extraction, the pontic, and the guided tissue 
regeneration. You say that you were charged a different amount of what you were told. The Plan denied your 
request. The Plan says the proper coinsurance was applied to the covered services and the denied services are 
not covered by the Plan's dental benefits. The rules say a plan must disclose to its enrollees in clear, accurate 
terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with 
the Plan clearly says that you must pay a 40% coinsurance for the following comprehensive dental services: 
prosthodontics, other oral/maxillofacial surgery, and other services. The total amount allowed for the crown 
was $618.38 with a coinsurance of $247.35 ($618.38 total amount allowed x 40% coinsurance). The total 
amount allowed for the extraction was $135.44 with a coinsurance of $54.17 ($135.44 total amount allowed x 40% coinsurance). The total amount allowed for the pontic was $509.25 with a coinsurance of $203.70 ($509.25 total amount allowed x 40% coinsurance). The second extraction total amount allowed was $135.44 with a coinsurance 
of $54.17 ($135.44 total amount allowed x 40% coinsurance). The second pontic total amount allowed was $509.25 with a coinsurance amount of $203.70 ($509.25 total amount allowed x 40% coinsurance amount). The total coinsurance 
amount was $763.09 ($247.35 coinsurance + $54.17 coinsurance + $203.70 coinsurance + $54.17 coinsurance + $203.70 
coinsurance). 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
You have been asked to pay a $763.09 coinsurance for the crown, the extractions, and the pontics, crown, the 
extractions, and the pontics 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the dental core buildups or tissue 
regeneration are not among those covered under this benefit. Therefore, we decided that the Plan does not have 
to pay for the core buildup (dental code D2950) the guided tissue regeneration (dental code D4266) or waive 
the coinsurance for the crown (dental code D6740), the extraction (dental code D7210), the pontic (dental code 
D6245) for tooth #18, #19, and #20 provided on January 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction (D7210), pontic-crown (D6245), and a retainer 
crown (D6740), provided by an out-of-network provider on January 12, 2022. 
 
You asked the Plan to pay for an extraction, pontic-crown, and a retainer crown. You say that you should not 
have to pay for this. 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 an 
extraction (D7210), pontic-crown (D6245), and a retainer crown (D6740), provided by an out-of-network 
provider on January 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on March 
3, 2022. 
 
You asked the Plan to pay for an evaluation. You say that the services were medically necessary. The Plan 
denied your request. The Plan says this service is covered by the Plan's dental benefits; however, your benefit 
for one comprehensive oral evaluation every three plan years. 
 
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 one 
comprehensive oral evaluation (D0150) every three plan years. 
 
We looked at this case file, the Plans rules, and Medicare rules. The record shows the Plan paid for a 
comprehensive oral evaluation provided on September 23, 2021; therefore, the benefit for a comprehensive oral 
evaluation has been exhausted. Therefore, we decided that the Plan does not have to pay for a comprehensive 
oral evaluation (D0150) provided on March 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bitewings x-rays (D0274), periodic oral evaluation (D0120) 
and prophylaxis (D1110) provided on March 18, 2021. 
 
You asked the Plan to pay for bitewings x-rays, periodic oral evaluation and prophylaxis. You say that the 
claims were denied because the office is not in Medicare, but this is a reimbursement plan. The Plan denied 
your request. The Plan says dental services received from a provider who has opted out of Medicare cannot be 
paid. 
 
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 contract says dental 
services received from a provider who has opted out of Medicare cannot be paid. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, dental services received from a 
provider that has opted out of Medicare are not covered. Therefore, we decided that the Plan does not have 
to pay for bitewings x-rays (D0274), periodic oral evaluation (D0120) and prophylaxis (D1110) provided on 
March 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the re-cementing of the crown on tooth #3 (D2920) provided 
on March 1, 2022. 
 
You asked the Plan to pay for re-cementing crown. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says re-cementing crown (D2920) is not covered by your dental 
benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the re-
cementing of the crown on tooth #3 (D2920) provided on March 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral exam (code D01410) you had with an oral 
surgeon on July 27, 2020. 
 
You asked the Plan to pay for the limited oral exam. You say that you were never advised of any limitations for 
your dental care and were never provided anything in writing.  You said that you needed to see an oral surgeon 
because a regular dentist could not manage your condition. The Plan denied your request. The Plan says you 
had already exhausted your benefit for this service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan's rules say that 
limited oral exams (code D0140) are only covered once per year.  You had already received a covered limited 
oral exam on February 25, 2020, so you were not eligible for another one on the date of service in question in 
this appeal. This limitation applies regardless of the reason for the exam. 
 
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 
limited oral exam (code D01410) you had with an oral surgeon on July 27, 2020.  
 
Your complaint about not being advised of any plan limitations and not being provided anything in writing is 
not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by 
the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a consultation (D9310) provided on March 8, 2022. 
 
You asked the Plan to pay for a consultation. You say that you disagree with the denial for dental services. The 
Plan denied your request. The Plan says a consultation (D9310) is not covered by your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
consultation (D9310) provided on March 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oral evaluation (dental code D0120) and a dental cleaning 
(dental code D1110) provided by an out-of-network provider on March 3, 2022. 
 
You asked the Plan to pay for an oral evaluation and a dental cleaning. You say that you have gone to this 
provider before, and the claims were paid. The Plan denied your request. The Plan says the denial for these 
services is correct because the rendering provider is an out-of-network (OON) provider. Also, the claim with a 
date of service of August 24, 2021, was paid due to a natural disaster declaration and the Plan sent out a letter 
advising the enrollee that OON providers would no longer be covered after January 16, 2022. 
 
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 contract says you 
may only receive benefits for covered services provided by a provider. 
 
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 when provided by an OON provider. Therefore, we decided that the 
Plan does not have to pay for an oral evaluation (dental code D0120) and a dental cleaning (dental code D1110) 
provided by an out-of-network provider on March 3, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for resin-based composite filling (D2391) provided on February 23, 2022. 
 
You asked the Plan to pay for a filling. You say that the dental services were medically necessary. The Plan 
denied your request. The Plan says that this service is covered by the Plan's dental benefits; however, your 
benefits for a filling has been exhausted. 
 
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 the complete Evidence of Coverage (EOC). Without 
the complete EOC we are unable to verify if the EOC provided is the correct one for your policy. Therefore, we 
decided that the Plan has to pay for resin-based composite filling (D2391) provided on February 23, 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 a limited oral evaluation (D0140) and cone beam imaging 
(D0367) provided on October 28, 2021, and intraoral x-rays (D0220) and extractions (D7210 x 2) provided on 
November 1, 2021. 
 
You asked the Plan to pay for an evaluation, imaging, x-rays, and extractions. You say that you did not know 
the provider had opted out of Medicare. The Plan denied your request. The Plan says this provider has opted 
out of Medicare and is not eligible for payment. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
We confirmed that the provider has opted out of Medicare. The services at issue in this appeal were provided in 
a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, 
we decided that the Plan does not have to pay for a limited oral evaluation (D0140) and cone beam imaging 
(D0367) provided on October 28, 2021, and intraoral x-rays (D0220) and extractions (D7210 x 2) provided on 
November 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam CT and extraction (D0365, D7210) provided on 
September 10, 2021. 
 
You asked the Plan to pay for the cone beam CT and extraction. 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 a cone 
beam CT and extraction (D0365, D7210) provided on September 10, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services provided on September 2, 2021, billed 
with codes 22853, 38220, 69990, and 20930. 
 
You asked the Plan to pay for the surgical services as billed. You say that this should be paid as billed due to 
medical necessity. The Plan denied your request. The Plan says there were not modifiers billed to bypass the 
PTP edits. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
CPT code 22853 is a Column 2 code in relation to 22849. There is a modifier indicator of 1, but no modifier 
was reported to bypass this edit. CPT code 38220 is Column 2 code in relation to 22551 and code 69990 is a 
Column 2 code in relation to both 22853 and 22551. These edits both have a modifier indicator of 0. 
 
Lastly, code 20930 has a status indicator of B on the Physician Fee Schedule, which means no separate 
payment can be made for this code. Based on this information, we decided that Medicare rules for coverage of 
the surgical services as billed have not been met. Therefore, we decided that the Plan does not have to pay for 
the surgical services provided on September 2, 2021, billed with codes 22853, 38220, 69990, and 20930.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prophylaxis (D1110) and the panoramic radiographic image 
(D0330) provided on January 4, 2022, and the resin-based composite (D2330) provided on February 7, 2022, 
by an out-of-network provider. 
 
You asked the Plan to pay for the radiographic image and composite. You say that at the time of enrollment 
with the Plan you were told these dental services would be covered. The Plan denied your request. The Plan 
says these services are not covered benefits and were provided out-of-network. 
 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 
prophylaxis (D1110) and the panoramic radiographic image (D0330) provided on January 4, 2022, and the 
resin-based composite (D2330) provided on February 7, 2022, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services coded 99100 provided on February 
23, 2021. 
 
You asked the Plan to pay for the anesthesia services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this code is not eligible for separate 
payment per Medicare rules. 
 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 CPT code 99100 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for the 
anesthesia services coded 99100 provided on February 23, 2021.