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

 
We decided that the Plan does not have to pay for the extractions (D7210) for tooth #5, #6, #7, #8, #9, and #10 
provided on February 10, 2021. 
 
You asked the Plan to pay for the dental services. You say that the procedures were medically necessary. The 
Plan denied your request. The Plan says your benefit for the requested item or service has already been 
exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service February 10, 2021. 
Therefore, we decided that the Plan does not have to pay for the extractions (D7210) for tooth #5, #6, #7, #8, 
#9, and #10 provided on February 10, 2021.  
 
Your complaint about your experience with this provider 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 the panoramic x-ray (D0330) and limited oral evaluation - 
problem focused (D0140) provided April 11, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told when you signed up for the Plan 
that services for your broken teeth would be covered. The Plan denied your request. The Plan says you have 
exceeded the frequency limit for the panoramic x-ray and the limited oral exam 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, certain limitations apply. The record 
shows your benefit for the panoramic x-ray was exhausted on date of service January 7, 2022. The limited oral 
exam is not among your covered services. Therefore, we decided that the Plan does not have to pay for the 
panoramic x-ray (D0330) and limited oral evaluation - problem focused (D0140) provided April 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87798 billed for date of service November 
10, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the code remains 
not supported. 
 
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, we have confirmed that code 87798 is a column II code to column I code 87801. The medical 
records provided do not show that the code at issue has not been billed with an appropriate modifier to bypass 
the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 87798 billed for date of service November 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a periodic oral evaluation (D0120), prophylaxis 
(D1110), and bitewing x-rays (D0274) provided on May 19, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you disagree with the allowed amounts for 
these services. The Plan denied your request. The Plan says you are responsible for any charged amount above 
the Plans cost-sharing amount when your services are received from an out-of-network provider. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to pay more for a periodic oral evaluation (D0120), 
prophylaxis (D1110), and bitewing x-rays (D0274) provided on May 19, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve a dental crown restoration for porcelain/ceramic for tooth #8.

You asked the Plan to pre-approve the crown. You say that this is medically necessary. The Plan denied your request. The Plan says that the tooth has to have a lot of tooth missing from a cavity or have a lot of damage from being broken and it can no longer be fixed with filling.

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 crown when the services are medically necessary and reasonable.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the crown. Our reviewer says that the requested dental services are medically reasonable and necessary. Our physician reviewer found that a review of the documentation indicates that tooth #8 exhibits significant incisal breakdown. A crown restoration is medically reasonable and necessary to provide adequate function and structural support in preventing further enamel fracture.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the crown have been met. Therefore, we decided that the Plan has to pre-approve a dental crown restoration for porcelain/ceramic for tooth #8. 

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 dental services (D7953, D4265, D9612, D9222, and D9223) 
on April 29, 2022. 
 
You asked the Plan to pay for dental services (D7953, D4265, D9612, D9222, and D9223). You say that you 
would like to appeal the denial of the claim. The Plan denied your request. The Plan says the services are not 
covered under the enrollee's benefit 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 dental 
services (D7953, D4265, D9612, D9222, and D9223) on April 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for five (5) acupuncture visits provided from 
December 2, 2021, to December 17, 2021, or pay for an office visit (99202) provided on December 2, 2021. 
 
You asked the Plan to waive the copayment for the acupuncture visits and to pay for the office visit. You say 
that you should be reimbursed through your Wellness benefit. The Plan denied your request. The Plan says the 
copayment was applied correctly and the office visit remains denied as a non-covered service. 
 
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 $10 per 
visit for Medicare-covered acupuncture services for chronic low back pain. Your contract with the Plan also 
clearly says that the office visit is a non-covered acupuncture service.  
 
You have been asked to pay $90 ($10 copay X 5 visits =$50 and $40 for office visit) for the acupuncture visits. 
Acupuncture visits fall within the Acupuncture for Chronic Low Back Pain 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 copayment for five (5) acupuncture visits provided from December 2, 2021, to 
December 17, 2021, and does not have to pay for an office visit (99202) provided on December 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve moderate sedation (CPT code 01992). 
 
You asked the Plan to pre-approve moderate sedation. You say that the service is medically necessary. The 
Plan denied your request. The Plan says your request is not medically necessary because the enrollee's records 
show they do not have documentation establishing a need for sedation during this procedure. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of moderate sedation have not been met. The rules say use of 
Moderate or Deep Sedation, General Anesthesia, and MAC is usually unnecessary or rarely indicated for these 
procedures and therefore, not considered medically reasonable and necessary. Therefore, we decided that the 
Plan does not have to pre-approve moderate sedation (CPT code 01992).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740) and an addition to a crown (D2954) for 
tooth #6 provided on March 14, 2022. 
 
You asked the Plan to pay for a crown and an addition to a crown. You say that you thought the insurance 
would cover these services. The Plan denied your request. The Plan says these services are not covered by the 
Plan's 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 crown 
(D2740) and an addition to a crown (D2954) for tooth #6 provided on March 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of torus mandibularis (D7473). 
 
You asked the Plan to pre-approve removal of torus mandibularis. You say that this service is medically 
necessary. The Plan denied your request. The Plan says the removal of torus mandibularis (D7473) is not 
covered by your routine 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 pre-approve the 
removal of torus mandibularis (D7473).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crown restorations (D2750) for teeth #8 & #10 provided 
by a participating provider. 
 
You asked the Plan to pre-approve a crown restoration. You say that D2750 is medically necessary. The Plan 
denied your request. The Plan says the requested services have been correctly denied. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers a crown 
restoration 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 a crown restoration. Our physician 
reviewer found the medical criteria for D2750 for teeth #8 & #10 have not been met. 
 
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 a crown restoration have not been met. Therefore, we decided that the Plan does 
not have to pre-approve crown restorations (D2750) for teeth #8 & #10 provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a maxillary partial denture (D5213) and a mandibular partial 
denture (D5214) provided on March 28, 2022. 
 
You asked the Plan to pay for the dental services. You say that the provider told you everything would be taken 
care of. The Plan denied your request. The Plan says your benefit for the requested items or services 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 items or services was exhausted on date of service January 29, 2019. 
Therefore, we decided that the Plan does not have to pay for a maxillary partial denture (D5213) and a 
mandibular partial denture (D5214) provided on March 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), intraoral x-rays (D0210), 
and a resin-based composite filling on tooth #1 (D2391) provided on January 4, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says the dental services were received from an out-of-network provider 
and are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a periodic oral evaluation (D0120), intraoral x-rays (D0210), and a resin-based composite filling on 
tooth #1 (D2391) provided on January 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a maxillary partial denture (D5213) provided on January 24, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were informed this would be covered at 
100% after January 1, 2022. 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 Plan's 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 July 23, 2019. Therefore, 
we decided that the Plan does not have to pay for a maxillary partial denture (D5213) provided on January 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the out-of-network (OON) dental services provided April 28, 
2022, to May 10, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were not aware that the dentist is OON. 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 Plan's 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 out-of-network (OON) dental services provided April 28, 2022, to May 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary and mandibular denture (D5110 
and D5120) provided by a participating provider. 
 
You asked the Plan to pre-approve a complete maxillary and mandibular denture. You say that you need these 
dentures. The Plan denied your request. The Plan says D5110 and D5120 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 a 
complete maxillary and mandibular denture (D5110 and D5120) provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for resin-based composite filling on tooth #4 (D2391) and resin-
based composite filling on tooth #31 (D2394) provided on November 1, 2021. 
 
You asked the Plan to pay for the dental services. You say that this provider is in-network. The Plan denied 
your request. The Plan says your benefit for the requested items or services 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 items or services was exhausted on date of service November 1, 2021. 
Therefore, we decided that the Plan does not have to pay for resin-based composite filling on tooth #4 (D2391) 
and resin-based composite filling on tooth #31 (D2394) provided on November 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller with related electronic 
connections and harness, and an attendant control. 
 
You asked the Plan to pre-approve the expandable controller and attendant control. You say that the request 
should be approved in full. The Plan denied your request. The Plan says there is no need for an expandable 
controller or attendant control. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that attendant controls are noncovered when provided along with 
a beneficiary-operated drive control. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the expandable controller and attendant 
control. Our reviewer says that the requested items are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the records provided document that the enrollee has 3/5 wrist and hand 
strength and is independent with eating, grooming and hygiene, thus indicating he has adequate upper 
extremity strength and function to operate the wheelchair's power options with their own switches.  
 
Since a non-expandable beneficiary drive control was approved, the attendant control cannot be covered. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the expandable controller and attendant control have not been met. Therefore, 
we decided that the Plan does not have to pre-approve an expandable controller with related electronic 
connections and harness, and an attendant control.
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), complete upper denture (D5110), and complete lower denture (D5120) provided March 30, 2022. 
 
You asked the Plan to pay for the dental services. You say that your provider gave you a lower estimate for the 
dentures. 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 Plan's 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 comprehensive exam was exhausted on date of service December 3, 2021. This 
benefit does not include complete upper or lower dentures as covered services.  Therefore, we decided that 
the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150), complete 
upper denture (D5110), and complete lower denture (D5120) provided March 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an occlusal adjustment - limited on April 27, 2022.

You asked the Plan to pay for an occlusal adjustment - limited. You say that you would like to appeal the denial of the claim. The Plan denied your request. The Plan says the service is not covered under the member's contract under any normal circumstances.

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 an occlusal adjustment - limited on April 27, 2022.