Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ViviGen cell retaining allograft (CPT code 20930). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says the clinical value and effectiveness of the ViviGen cell retaining allograft in the setting 
of spinal fusion surgery has not been demonstrated in the peer-reviewed literature. 
 
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 the service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception to guidelines. Therefore, the requested ViviGen cell retaining 
allograft in the setting of spinal fusion surgery, in this case, is not medically reasonable or 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 the service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve ViviGen cell retaining allograft (CPT code 20930).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for consultation (D9310), biologic materials to aid in soft and 
osseous tissue regeneration, per site (D4265), guided tissue regeneration - resorbable (D4266) and bone 
replacement graft (D7953) provided on March 28, 2022, to May 2, 2022. 
 
You asked the Plan to pay for consultation (D9310), biologic materials to aid in soft and osseous tissue 
regeneration, per site (D4265), guided tissue regeneration - resorbable (D4266) and bone replacement graft 
(D7953). You say that you would like the plan to pay for your dental services. The Plan denied your request. 
The Plan says this service 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 pay for 
consultation (D9310), biologic materials to aid in soft and osseous tissue regeneration, per site (D4265), guided 
tissue regeneration - resorbable (D4266) and bone replacement graft (D7953) provided on March 28, 2022, to 
May 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on November 4, 2021 billed with 
codes 81407, 81408, and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
November 4, 2021 billed with codes 81407, 81408, and 81479.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core build up on tooth #5 (D2950) provided on January 4, 
2022, a periapical x-ray (D0220) provided on January 18, 2022, and core build up on tooth #30 (D2950) and a 
crown on tooth #30 (D2740) provided on April 19, 2022. You asked the Plan to pay for the dental services. You say that you were told these procedures were covered. 
The Plan denied your request. The Plan says core build up (D2950) is not covered by your dental benefits. The 
Plan also says that your benefit for periapical x-rays has already been exhausted. The Plan also says that your 
annual dental maximum has been met. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that this benefit includes 
coverage up to $2,000 for only the items and services listed in the Mandatory Supplemental Dental Benefits 
chart. 
 
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, core build up is not among those 
covered under this benefit. The record shows your benefit for periapical x-rays was exhausted on date of 
service February 17, 2022.   
 
The record also shows your annual dental maximum benefit has been met. You are responsible for any amount 
above the benefit maximum. Core build up, periapical x-rays, and crowns fall within the Dental Services 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to pay for core build up on tooth #5 (D2950) provided on 
January 4, 2022, a periapical x-ray (D0220) provided on January 18, 2022, and core build up on tooth #30 
(D2950) and a crown on tooth #30 (D2740) provided on April 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0378 billed for date of service December 
27, 2021. 
 
You asked the Plan to pay for procedure code G0378. You say that this was medically necessary. The Plan 
denied your request. The Plan says the billed code cannot be paid. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code.  
We find that procedure code G0378 has a Status Indicator of X on the Physician Fee Schedule. This means that 
procedure code G0378 is a statutory exclusion, and no payment may be made under the physician fee schedule. 
Based on this information, we decided that Medicare rules for coverage of procedure code G0378 have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure code G0378 billed for date of 
service December 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services (D1206, D2950, D4346) provided on 
February 17, 2022, and March 31, 2022  
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your dental maximum allowance of $2,000 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 03/31/2022. Therefore, 
we decided that the Plan does not have to pay for dental services (D1206, D2950, D4346) provided on 
February 17, 2022, and March 31, 2022
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction, erupted tooth requiring removal of bone 
(D7210), extraction, erupted tooth or exposed root (D7140), immediate denture - maxillary (D5130), and 
unspecified removable prosthodontic procedure (D5899) provided on March 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that you received a written document prior to any 
dental work containing what the Plan will cover and the remaining would be your responsibility. The Plan 
denied your request. The Plan says these services are not covered under the dental package. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an 
extraction, erupted tooth requiring removal of bone (D7210), extraction, erupted tooth or exposed root 
(D7140), immediate denture - maxillary (D5130), and unspecified removable prosthodontic procedure (D5899) 
provided on March 22, 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 May 
27, 2022. 
 
You asked the Plan to pay for the dental services. You say that you needed to see another provider. 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 June 4, 2021, and 
October 19, 2021. Therefore, we decided that the Plan does not have to pay for a comprehensive oral 
evaluation (D0150) provided on May 27, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital admission related to a surgical 
total shoulder replacement. 
 
You asked the Plan to pre-approve acute inpatient hospital admission. You say that the requested inpatient 
admission is a medical necessity for the enrollee. The Plan denied your request. The Plan says medical-
necessity rules for inpatient admission have not been met. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. 
 
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 acute inpatient hospital admission. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found that the record does not show that at the time of inpatient admission, the 
admitting physician would reasonably expect that the enrollee's necessary hospital care will span two 
midnights. Detailed documentation is not evident regarding a significant past and/or current medical history 
that would place the enrollee at increased risk for peri-surgical complications requiring an inpatient stay.  There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity 
of this request as an exception. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital admission have not been met. Therefore, we decided 
that the Plan does not have to pre-approve acute inpatient hospital admission related to a surgical total shoulder 
replacement.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bone replacement (D77953), the extractions (D7210), the 
guided tissue regeneration (D4266) provided on April 12, 2022. 
 
You asked the Plan to pay for the dental services. You say that you received documentation from the Plan that 
your dental allowance will increase. The Plan denied your request. The Plan says the denial of payment for the 
dental services is correct, because the enrollee does not have non-Medicare dental benefits with the Plan. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
  The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for the bone replacement (D77953), 
the extractions (D7210), the guided tissue regeneration (D4266) provided on April 12, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ten (10) additional home health physical therapy visits 
for the enrollee. 
 You asked the Plan to pre-approve ten (10) additional home health physical therapy visits. You say that these 
services are medically necessary. The Plan denied your request. The Plan says that the medical record does not 
document a clearly evident need for the services of a skilled physical therapist. 
 
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 ten (10) additional home health 
physical therapy visits. Our reviewer says that ten (10) additional home health physical therapy visits are not 
medically reasonable and necessary. The enrollee does not have documented, ongoing, home health physical 
therapy needs. The enrollee is functioning at a level commiserate with a lower level of care. Our physician 
reviewer found that the enrollee's condition does not meet criteria for coverage of ten (10) additional home 
health physical therapy visits. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ten (10) additional home health physical therapy visits have not been met. 
Therefore, we decided that the Plan does not have to pre-approve ten (10) additional home health physical 
therapy visits for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an incision and drainage of abscess (10061) billed for date of 
service July 20, 2021. 
 
You asked the Plan to pay for an incision and drainage of abscess. You say that the services at issue were billed 
correctly. The Plan denied your request. The Plan says rules for payment have not been met because the 
available records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 10061 is "Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); complicated or 
multiple." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for an incision and drainage of abscess. Our reviewer says that 
the CPT code at issue does not meet criteria for payment. Our reviewer found that the available procedure 
report does not include documentation of a complicated or multiple incision and drainage of abscess, and 
therefore the service billed cannot be verified. There is a more appropriate code to report for a simple incision 
and drainage of abscess. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an incision and drainage of abscess have not been met. Therefore, we decided 
that the Plan does not have to pay for an incision and drainage of abscess (10061) billed for date of service July 
20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown on tooth #11 (D2740) and prefabricated post in 
addition to crown on tooth #11 (D2954) provided on May 10, 2022. 
 
You asked the Plan to pay for the dental services. You say that you decided to have the procedure so that you 
would not lose the tooth. 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 16, 2018. 
Therefore, we decided that the Plan does not have to pay for a crown on tooth #11 (D2740) and prefabricated 
post in addition to crown on tooth #11 (D2954) provided on May 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on March 1, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the member's benefit of $1000 was already 
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. Therefore, we decided that the Plan does 
not have to pay for the dental services on March 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213) and platelet rich plasma (PRP) 
provided on November 29, 2021. 
 
You asked the Plan to pay for PRP. You say that the services should be covered. The Plan denied your request. 
The Plan says there was no documentation of chronic non-healing wounds and therefore the services are not 
covered. 
 
The Plan follows Medicare rules. Medicare rules say that will cover autologous PRP for the treatment of 
chronic non-healing diabetic wounds. 
 
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 pay for PRP. Our reviewer says that the PRP 
injections were not medically necessary. Our physician reviewer found the provided documentation does not 
support a covered indication for PRP injection. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PRP have not been met. Therefore, we decided that the Plan does not have to 
pay for the office visit (99213) and platelet rich plasma (PRP) provided on November 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mass spectrometry and tandem mass spectrometry 
services coded 83789 provided on March 1, 2022. 
 
You asked the Plan to pay for the mass spectrometry and tandem mass spectrometry services. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the services billed are not 
separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
In this case, the CPT Code Manual definition of code 83789 is mass spectrometry and tandem mass 
spectrometry (eg, MS, MS/MS, MALDI, MS-TOF, QTOF), non-drug analyte(s) not elsewhere specified, 
qualitative or quantitative, each specimen. 
 
We find that CPT code 83789 is not supported in the medical record. Specifically, the medical records provided 
indicate that the urine specimen was collected for drug testing. When specimen validity testing is conducted as 
part of drug testing, it cannot be billed separately. Therefore, the billed code and appended modifier cannot be 
verified. Based on this information, we decided that Medicare rules for coverage of the mass spectrometry and 
tandem mass spectrometry services have not been met. Therefore, we decided that the Plan does not have to 
pay for the mass spectrometry and tandem mass spectrometry services coded 83789 provided on March 1, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vitoss Allograft and Stryker BIO4 (CPT code 20930). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says the clinical value and effectiveness of Isto InQu allograft in the setting of spinal fusion 
surgery have not been demonstrated in the peer-reviewed literature. 
 
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 the service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found Vitoss allograft and Stryker Bio4 are experimental for use in spine surgery. 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 the service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Vitoss Allograft and Stryker BIO4 (CPT code 20930).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service May 10, 
2022. 
 
You asked the Plan to pay for procedure code 76705. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 76705 is bundled into payment for code 93976. 
 
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 76705 
is a column II code to column I code 93976. This claim 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 76705 billed for date of service May 10, 2022.