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

 
We decided that the Plan does not have to pay for mass spectrometry and tandem mass spectrometry (83789) 
billed for date of service February 23, 2022. 
 
You asked the Plan to pay for mass spectrometry services. You say that these services were necessary and are 
supported as billed. The Plan denied your request. The Plan says they have agreed to pay for codes G0481 and 
80307; however, 83789 is specimen validity testing which is not separately payable from these drug testing 
services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of mass spectrometry services have not been met. Specifically, we find that the testing described by the billed code is considered specimen validity testing which is not separately payable. Therefore, we decided 
that the Plan does not have to pay for mass spectrometry and tandem mass spectrometry (83789) billed for date 
of service February 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a power seat elevation system (E2300), and expandable 
controller (E2377), and electronic connections (E2311). 
 
You asked the Plan to pay for the power wheelchair components E2300, E2377, and E2311. You say that the 
requested items should be approved. The Plan denied your request. The Plan says as the power seat elevation 
feature cannot be covered, the expandable controller is not needed for the covered features. 
 
The Plan must follow Medicare rules. Medicare rules say that power seat elevation features are noncovered, 
and an expandable controller is used for either other types of input devices or to operate 3 or more power 
seating actuators.  
We looked at the file and Medicare rules. In this case, the only two covered power seating actuators are power 
tilt and power elevating legrests. These can be accommodated in the non-expandable controller. There is also 
no other input device being requested which would warrant this type of controller. The electronic connections 
related to this controller are also not covered. Based on this information, we decided that Medicare rules for 
coverage of the power wheelchair components E2300, E2377, and E2311 have not been met. Therefore, we 
decided that the Plan does not have to pay for a power seat elevation system (E2300), and expandable 
controller (E2377), and electronic connections (E2311).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided by a participating 
provider on July 7, 2022. 
 
You asked the Plan to pay for a limited oral evaluation. You say that you believe this should be covered 
because these services were medically necessary. The Plan denied your request. The Plan says D0140 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 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 limited 
oral evaluation (D0140) provided by a participating provider on July 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve five crowns (D2740 x5). 
 
You asked the Plan to pre-approve the crowns. You say that it is your understanding that these crowns should 
be covered. The Plan denied your request. The Plan says crowns are 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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve five 
crowns (D2740 x5).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown on tooth #12 (D2740). 
 
You asked the Plan to pre-approve a crown. You say that you disagree with the denial of dental services. The 
Plan denied your request. The Plan says a crown (D2740) 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 pre-approve a 
crown on tooth #12 (D2740).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for infectious disease pathogen identification testing provided on
May 26, 2022.

You asked the Plan to pay for infectious disease pathogen identification testing. You say that this test is not
experimental and was medically necessary. The Plan denied your request. The Plan says his panel was not
billed in accordance with Medicare rules.

The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as
individual components regardless of the fact that the test reports multiple individual pathogens and/or targets.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of infectious disease pathogen identification testing have not been met. Specifically, the records show
that a single panel was ordered and performed, but this service was billed by reporting individual components.

Therefore, we decided that the Plan does not have to pay for infectious disease pathogen identification testing
provided on May 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve provisional retainer crowns on tooth #4, 5, 9, and 10 
(D6793). 
 
You asked the Plan to pre-approve retainer crowns. You say that this service is covered and that you want it 
approved. The Plan denied your request. The Plan says you are missing other teeth. 
 
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 retainer 
crowns 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 retainer crowns. Our reviewer says that 
the coverage criteria has not been met. Our physician reviewer found that a review of the documentation 
indicates that tooth #2, 3, 6 and 7 are missing and tooth #8 is to be extracted. The documentation provided does 
not meet the criteria for coverage for a fixed bridge and services associated with a fixed bridge (provisional 
crowns). 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 retainer crowns have not been met. Therefore, we decided that the Plan does not 
have to pre-approve provisional retainer crowns on tooth #4, 5, 9, and 10 (D6793).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an occlusal guard (D9944). 
 
You asked the Plan to pre-approve the dental services. You say that you have a dental rider, and this service 
should be covered. 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 annual maximum dental benefit was exhausted on date of service May 26, 2022. Therefore, we 
decided that the Plan does not have to pre-approve an occlusal guard (D9944).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve osseous dental surgery (D4260) 
 
You asked the Plan to pre-approve the osseous dental surgery. 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 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 
osseous dental surgery (D4260) .
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a limited oral evaluation (D1040) provided by a 
participating provider on June 8, 2022. 
 
You asked the Plan to pre-approve the dental services. You say that this evaluation is 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 14, 2022. 
Therefore, we decided that the Plan does not have to pre-approve a limited oral evaluation (D1040) provided 
by a participating provider on June 8, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional skilled nursing visits (G0299 x 3). 
 You asked the Plan to pre-approve 3 additional home health visits. You say that the requested services are 
necessary for the enrollee. The Plan denied your request. The Plan says the requested services are not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve 3 additional home health visits. Our 
reviewer says that the additional home health visits are not medically necessary. Our physician reviewer found 
the provided documentation does not indicate the enrollee has documented skilled nursing needs. The reviewer 
found that laboratory draws alone, are not an indication for home health skilled nursing visits. The reviewer 
found that the enrollee is noted to have paid help. Therefore, the reviewer found that the requested additional 
home health visits are not medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 3 additional home health visits have not been met. Therefore, we decided that 
the Plan does not have to pre-approve additional skilled nursing visits (G0299 x 3).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 7, 2021, billed with 
codes 81408, 81162, 81406, 81292, 81321, 81407 and 81351. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was necessary and is 
supported as billed. The Plan denied your request. The Plan says this claim was not billed in accordance with 
Medicare rules. 
 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 
October 7, 2021, billed with codes 81408, 81162, 81406, 81292, 81321, 81407 and 81351.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone replacement graft for ridge preservation - per site 
(D7953), and immediate denture - mandibular (D5140) provided on March 8, 2022. 
 
You asked the Plan to pay for a bone replacement graft for ridge preservation - per site (D7953), and 
immediate denture - mandibular (D5140). You say that you are asking the Plan to allow access to the full 
$2,000 dental benefit. The Plan denied your request. The Plan says the dental services 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. 
 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 bone 
replacement graft for ridge preservation - per site (D7953), and immediate denture - mandibular (D5140) 
provided on March 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an apicoectomy - anterior (D3410) provided by an out-of-
network provider on June 10, 2022. 
 
You asked the Plan to pay for an apicoectomy. You say that these services were necessary for overall dental 
health, and to prevent more expensive procedures in the future. The Plan denied your request. The Plan says 
these services are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an 
apicoectomy - anterior (D3410) provided by an out-of-network provider on June 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740) provided by a participating provider on 
April 29, 2022. 
 
You asked the Plan to pay for a crown. You say that the Plan should pay for this. The Plan denied your request. 
The Plan says the rendered dental 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 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) provided by a participating provider on April 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740) for tooth #29 provided by a participating 
provider on June 15, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are on a limited income, and you cannot 
afford this. 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. Therefore, 
we decided that the Plan does not have to pay for a crown (D2740) for tooth #29 provided by a participating 
provider June 15, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ViviGen cellular allograft services. 
 
You asked the Plan to pre-approve ViviGen cellular allograft services. You say that this procedure is medically 
reasonable and necessary. The Plan denied your request. The Plan says the requested procedure is considered 
experimental/investigational. 
 
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 ViviGen cellular allograft services. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that the enrollee is a 73-year-old male being treated for spinal stenosis of 
the cervical region; disease of the spinal cord, unspecified. They presented with gait and balance that are off 
and has a history of falls. The exam reveals a limited range of motion in the cervical spine. There is a loss of fine rapid motor movements in the upper extremities. The health plan approved the C2-C7 multilevel 
laminectomy with posterolateral fusion. 
 
However, there is limited published, large-scale, long-term peer-reviewed literature that shows the requested 
allograft, ViVigen, to be an effective and/or safe treatment for the noted pathology. The peer-reviewed 
literature has not demonstrated that the use of the allograft is of greater efficacy than an autograft or cage. 
There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity 
of this request as an exception. Therefore, the requested ViVigen cellular allograft, 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 ViviGen cellular allograft services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve ViviGen cellular allograft services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a gingivectomy (D4212) 
 
You asked the Plan to pre-approve the gingivectomy. 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 Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
gingivectomy (D4212)
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller and related accessories 
(E2311, E2377, E2313). 
 You asked the Plan to pre-approve an expandable controller and related accessories. You say that this 
expandable controller is medically necessary for your wheelchair. The Plan denied your request. The Plan says 
the criteria for coverage have not been met for the requested expandable controller. 
 
The Plan follows Medicare rules. Medicare rules say that an expandable controller is subject to the criteria 
listed in the Medicare rules section. 
 
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 an expandable controller and related 
accessories. Our reviewer says that the requested expandable controller and related accessories are not 
medically reasonable and necessary. Our physician reviewer found that you do not require a ventilator, or non-
proportional input devices (e.g., sip and puff, head array, etc.). In addition, you do not require a separate 
display (i.e., for alternate control devices), other electronic devices (e.g., control of an augmentative speech 
device or computer through the chair's drive control), or an attendant control. You have power options on the 
wheelchair but do not need to control the power options through a joystick as your right upper extremity 
strength supports that the patient can control any power options through their own switches. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an expandable controller and related accessories have not been met. Therefore, 
we decided that the Plan does not have to pre-approve an expandable controller and related accessories (E2311, 
E2377, E2313).