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

 
We decided that the Plan does not have to pay for the surgical placement of implant body: endosteal implant 
(D6010) provided January 19, 2022. 
 
You asked the Plan to pay for the endosteal implant. You say that you were not aware this provider was out-of-
network. The Plan denied your request. The Plan says you have been given a one-time exception and the claims 
from this date-of-service have been re-processed as in-network. However, the endosteal implant is not 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 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 
surgical placement of implant body: endosteal implant (D6010) provided January 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (dental code D0140) and a 
panoramic x-ray (dental code D0330) provided on February 18, 2022. 
 
You asked the Plan to pay for a limited oral evaluation and a panoramic x-ray. You say that you went to the 
dentist for a tooth extraction and the dentist had to examine the area before doing the extraction. The Plan 
denied your request. The Plan says that the limited oral evaluation is not a covered benefit under the enrollees 
dental benefits. The Plan also says that the panoramic x-ray is covered by the Plans dental benefits; however, 
your benefit for the panoramic x-ray has been exhausted. 
  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers 1 panoramic 
x-ray every 36 months. 
 
We looked at this the file, the Plans rules, and Medicare rules. You previously received a panoramic x-ray on 
January 10, 2022; therefore, the benefit for this service was exhausted on February 18, 2022. Additionally, the 
limited oral evaluation is not covered by the Plan. Based on this information, we decided that the Plans rules 
for coverage of dental services have not been met. Therefore, we decided that the Plan does not have to pay for 
a limited oral evaluation (dental code D0140) and a panoramic x-ray (dental code D0330) provided on 
February 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a consultation (D9310), a prefabricated abutment (D6056), 
prophylaxis (D1110), a periodic oral evaluation (D0120), and resin-based composites (D2335 and D2330), 
provided by an out-of-network provider on January 20, 2021, to September 28, 2021. 
 
You asked the Plan to pay for a consultation, a prefabricated abutment, prophylaxis, a periodic oral evaluation, 
and resin-based composites. You say that you expected the Plan to have better coverage. The Plan denied your 
request. The Plan says the rendered services have been 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.  
 
 We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of prophylaxis, a periodic oral evaluation, and resin-based composites have been processed correctly. 
A consultation and a prefabricated abutment are not covered dental services. Therefore, we decided that the 
Plan does not have to pay for a consultation (D9310), a prefabricated abutment (D6056), prophylaxis (D1110), 
a periodic oral evaluation (D0120), and resin-based composites (D2335 and D2330), provided by an out-of-
network provider on January 20, 2021, to September 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the occlusal guard - soft appliance, full arch (dental 
code D9945). 
 
You asked the Plan to pre-approve the occlusal guard - soft appliance, full arch. You say that the occlusal guard 
is necessary because the dentist think the enrollee will grind out their fillings. The Plan denied your request. 
The Plan says the denial of authorization for this service is correct, because the occlusal guard 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 
occlusal guard - soft appliance, full arch (dental code D9945).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of impacted tooth (dental code D7230) for 
tooth #17. 
 
You asked the Plan to pre-approve removal of impacted tooth. You say that the service is medically necessary 
because the tooth has been infected and it is causing pain. The Plan denied your request. The Plan says 
reconsideration for the denial of removal of impacted tooth partially bony (tooth #17). The Plan denied request 
because it is not a covered benefit. Per Medicare rules extraction of teeth is only covered to prepare the jaw for 
radiation treatments of neoplastic cancer disease. The records show the extractions are due to impacted wisdom 
teeth and are therefore not covered by Medicare. Surgical extractions are also not covered by the Plan's 
enhanced supplemental dental benefit. 
  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers removal of 
impacted tooth for simple extractions, but not for surgical extractions 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 removal of impacted tooth. Our 
reviewer says that Medicare does not provide for treatment of the teeth or its supporting structures.  The 
supplemental plan provides for simple extractions, but not for surgical extractions.  The tooth requires removal 
of bone in order to extract it from the dental arch, and there is no manner to remove it as a simple (non-cutting) 
procedure.  Given the Plan limitations on coverage limits, the criteria for coverage did not exist for the 
procedure. Our physician reviewer found the request was made for a surgical extraction of tooth #17.  The 
tooth, #17, is a partial bony impaction and would require surgical removal if indicated.  The record indicates 
that the tooth had become infected several time per year, but the type of infection is not clear. Due to the 
positioning of the tooth, it is likely that the issue is a pericoronitis, where the tissue around the tooth becomes 
inflamed and possibly infected due to its position in the arch.  Where there are recurrent issues with inflamed 
and infected tissues around a molar an extraction is usually indicated and would be considered medically 
necessary. 
 
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 removal of impacted tooth have not been met. Therefore, we decided that the 
Plan does not have to pre-approve removal of impacted tooth (dental code D7230) for tooth #17.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an out-of-network provider on 
August 18, 2021. 
 
You asked the Plan to pay for dental services. You say that you have severe dry mouth syndrome that has cause 
tooth decay through the years. You say that these services were necessary. The Plan denied your request. The 
Plan says services provided by an out-of-network provider 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. The Plan covers covered 
dental services when the services are provided by an in-network provider. 
 
We looked the file and Medicare rules. The rendering dentist is not a participating provider. 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 dental services provided by an out-of-network provider on 
August 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis (D1110) provided by an out-of-network 
provider on February 15, 2022. 
 
You asked the Plan to pay for the prophylaxis (D1110). You say that the sales agent did not check with you 
regarding the dentist's participatory status, and you should have been given a choice of in-network dentists. The 
Plan denied your request. The Plan says the claim was 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 prophylaxis (D1110) is among 
those covered under this benefit. The record shows the provider was out-of-network and you were charged 
correctly. See chart below. 
  
 
Date of 
Service 
Service Provider 
Charge 
(PC) 
Allowed 
Amount 
(AA) 
Coinsurance Coinsurance 
Amount 
Difference 
between 
PC and 
AA 
Member 
Liability 
February 
15, 2022 
D1110 $100 $39.00 50% $19.50 $61.00 $80.50 
Total       $80.50 
 
Therefore, we decided that the Plan does not have to pay for the prophylaxis (D1110) provided by an out-of-
network provider on February 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve all white glass crown. 
 
You asked the Plan to pre-approve all white glass crown. You say that you would like to appeal the denial of 
the service. The Plan denied your request. The Plan says the all white glass crown is denied due to our dentist 
looked at your x-rays sent by your dentist. Your tooth has too little bone in the middle of the roots. Your tooth 
would need to have more bone in the middle of the roots to be allowed. We have also told your dentist. Please talk to your dentist. 
 
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 all 
white glass crown.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom abutment (D6057) and abutment supported 
porcelain/ceramic crown (D6058) for tooth #20 and 21. 
 
You asked the Plan to pre-approve the abutments and crowns. You say that you are having difficulty eating and 
have lost weight. The Plan denied your request. The Plan says the requested services are not covered by your 
supplemental 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 pre-approve 
custom abutment (D6057) and abutment supported porcelain/ceramic crown (D6058) for tooth #20 and 21.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endosteal implants (D6010) to be provided by a network 
provider. 
 
You asked the Plan to pre-approve the endosteal implants (D6010). You say that you are appealing the denial 
of the authorization for the dental implants. 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 endosteal implants (D6010) are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
endosteal implants (D6010) to be provided by a network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite (D2391) provided by a network 
provider on January 6, 2022. 
 
You asked the Plan to pay for the resin-based composite (D2391). You say that the cavity was rendered as a 
preventive procedure and should have been covered in full or at least in part. 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 resin-based composite (D2391) is 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
resin-based composite (D2391) provided by a network provider on January 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on October 4, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on October 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal of fixed orthodontic appliances (D8695) 
provided by an out-of-network provider on February 25, 2022. 
 
You asked the Plan to pay for the removal of fixed orthodontic appliances. You say that you had a fixed 
orthodontic appliance for 37 years and it broke. You say that you need these services. The Plan denied your 
request. The Plan says the rendered dental work 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 pay for the 
removal of fixed orthodontic appliances (D8695) provided by an out-of-network provider on February 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation feature, attendant mount, 
enhanced display kit, drive control harness, and display shroud for a power wheelchair.  
You asked the Plan to pre-approve power seat elevation feature, attendant mount, enhanced display kit, drive 
control harness, and display shroud. You say that the enrollee needs these components. The Plan denied your 
request. The Plan says the denial of authorization for these components is correct, because a power seat 
elevation feature is not covered by Medicare, an attendant control provided in addition to a beneficiary-
operated drive control system is non-covered, a drive control harness is part of an expandable controller and 
should not be requested separately, and a display shroud does not serve a primarily medical purpose. 
 
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature is not covered by 
Medicare, an attendant control will be denied if provided in addition to a beneficiary-operated drive control 
system, and components/features of an expandable controller should not be separately requested with code 
K0108. Medicare rules say that for equipment to be covered, it must serve a primarily medical purpose.  
 
We looked at the file and Medicare rules. The requested power seat elevation feature and attendant control are 
non-covered. The requested enhanced display kit and drive control harness should not be requested separately 
because they are already part of the expandable controller and harness. The requested display shroud does not 
serve a purpose that is primarily medical in nature, so is not covered by Medicare. Based on this information, 
we decided that Medicare rules for coverage of power seat elevation feature, attendant mount, enhanced display 
kit, drive control harness, and display shroud have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power seat elevation feature, attendant mount, enhanced display kit, drive control 
harness, and display shroud for a power wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the replacement of replaceable part of semi-precision or 
precision attachment of implant/abutment supported prosthesis, per attachment (D6091) provided November 
30, 2021. 
 
You asked the Plan to pay for the replacement of semi-precision or precision attachment. 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 
replacement of replaceable part of semi-precision or precision attachment of implant/abutment supported 
prosthesis, per attachment (D6091) provided November 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the white glass with metal crown (dental code D2751) 
for tooth #22. 
 
You asked the Plan to pre-approve the white glass with metal crown. You say that the service is necessary, and 
this is the only crown the provider can do. The Plan denied your request. The Plan says the denial of 
authorization for this service is correct because the white glass with metal crown is not covered under the 
enrollee's supplemental 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 pre-approve the 
white glass with metal crown (dental code D2751) for tooth #22.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on June 7, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
 We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on June 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a crown (D2740) provided by a 
participating provider on April 13, 2021. 
 
You asked the Plan to waive the coinsurance for a crown. You say that you want the Plan to pay for more than 
50%. The Plan denied your request. The Plan says the correct coinsurance has been applied. 
 
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 50% 
coinsurance for dental services/comprehensive dental.  
 
You have been asked to pay a 50% coinsurance of the allowed amount for a crown. The total allowed amount 
is $738. The total amount you are being asked to pay is $369 (D738 x 50% = $369). The correct coinsurance 
has been applied to the crown that were provided. A crown falls within the dental services/comprehensive 
dental 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 coinsurance for a crown (D2740) provided by a 
participating provider on April 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for the crown - porcelain/ceramic 
(D2740) provided December 29, 2021. 
 
You asked the Plan to provide additional payment for the crown. You say that you thought this service was 
covered. The Plan denied your request. The Plan says you have exhausted your dental benefit for 2021. 
 
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 crown up 
to the maximum annual allowance of $2,500. 
 
We looked at the file and Medicare rules. The Plan provided documentation showing that at the time of the 
service you had $780 remaining in your annual dental maximum. This amount was applied to you claim 
leaving you with an $80 cost-share for the service. This mean you have been asked to pay the correct amount 
based on your contract with the Plan.  Therefore, we decided that the Plan does not have to provide additional 
payment for the crown - porcelain/ceramic (D2740) provided December 29, 2021.