Persius/hicric huggingface dataset:
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that providers must report services correctly. Procedures should be reported with the CPT code 
that describes the services performed. You can find this rule in the Medicare National Correct Coding Initiative 
Manual, Chapter I(A). 
 
The rules say effective July 1, 2017, laboratories with 1 to 4 gene(s) on their targeted NGS panel should use 
CPT 81479 and one (1) UOS along with their test identifier (DEX Z-Code) to represent this service on their 
claims. Tier 1 and/or Tier 2 individual biomarker CPT codes should not be used for a single gene or any 
combination of genes when testing is performed as part of a NGS or other multiplexing technology panel. As 
CGP testing is not defined as a targeted panel by MolDX, and it is a test not currently satisfactorily described 
by any existing CPT code. Therefore, to report a CGP service, test providers should use CPT code 81479 at this 
time, in addition to the approved DEX Z-Code for the test. Coverage of CGP is limited to one test per surgical 
specimen and precludes the use of any other molecular testing on that specimen. For NGS-based tests that do 
not fit under the above definitions of 'targeted' or 'Comprehensive' panels, billing with the 'Not Otherwise 
Classified' (NOC) code 81479 along with the approved DEX Z-Code identifier is appropriate. You can find 
this in the Local Coverage Article: Billing and Coding: MolDX: Targeted and Comprehensive Genomic Profile 
Next-Generation Sequencing Testing in Cancer (A55624), Local Coverage Article: Billing and Coding: 
MolDX: Guardant360 Plasma-Based Comprehensive Genomic Profiling in Non-Small Cell Lung Cancer 
(NSCLC) (A57425) and  Local Coverage Determination (LCD) MolDX: Guardant360 Plasma-Based 
Comprehensive Genomic Profiling in Non-Small Cell Lung Cancer (NSCLC) (L37649). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that providers must report services correctly. Procedures should be reported with the CPT code 
that describes the services performed. You can find this rule in the Medicare National Correct Coding Initiative 
Manual, Chapter I(A). 
 
The rules say that for definitive drug testing, limitations apply when denials are likely, whether based on 
medical necessity or other coverage reasons. The limitation of liability and refund requirements do not apply 
when the test, item or procedure is statutorily excluded, has no Medicare benefit category or is rendered for 
screening purposes. For codes G0480, G0481, G0482, G0483, G0659, 80305, 80306, and 80307, diagnosis 
codes and physician documentation must be coded to the highest level of specificity. You can find this in the 
Local Coverage Article: Billing and Coding: Drug Testing (A56645).  
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare will not pay for dental services. Dental services are items and services involving 
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare 
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, 
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this 
rule in the SSA, Section 1862(a)(12) and Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. The contract lists the specific 
dental services that are covered by the Plan. Incision and drainage of an abscess is not listed and therefore is 
not a covered service. You can find this information on pages 74 to 83 of the Plan's 2020 Evidence of 
Coverage. 
 
The contract also says any procedure that is not specifically listed in the Benefits Chart are excluded from 
coverage. You can find this information on page 99 of the Plan?s 2020 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that provisions in this LCD and related coding article only address Vertebral Augmentation for 
Osteoporotic Vertebral Compression Fracture (VCF). Coverage will remain available for medically necessary 
procedures for other conditions not included in this LCD. 
 
PVA (percutaneous vertebroplasty (PVP) or kyphoplasty (PKP)) is covered in patients with BOTH the 
following: 
 
    1. Inclusion criteria (ALL are required): 
        a. Acute* (< 6 weeks) osteoporotic VCF (T5 ? L5) by recent (within 30 days) advanced imaging (bone 
marrow edema on MRI or bone-scan/SPECT/CT uptake) (1-3,10,25) 
        b. Symptomatic (ONE): 
            i. Hospitalized with severe pain (Numeric Rating Scale (NRS) or Visual Analog Scale (VAS) pain score 
= 8) (4-7) 
            ii. Non-hospitalized with moderate to severe pain (NRS or VAS =5) despite optimal non-surgical 
management (NSM) (10)** (ONE): 
                1. Worsening pain 
                2. Stable to improved pain (but NRS or VAS still =5) (with = 2 of the following): 
                    A. Progression of vertebral body height loss 
                    B. > 25% vertebral body height reduction 
                    C. Kyphotic deformity 
                    D. Severe impact of VCF on daily functioning (Roland Morris Disability Questionnaire (RDQ) 
>17 
        c. Multidisciplinary team consensus (2) (ALL are required)  
            i. Referring physician (e.g., rheumatologist, endocrinologist) 
            ii. Treating physician (i.e., performing the PVA) 
            iii. Radiologist 
            iv. Neurologist 
 
    2. Exclusion criteria (2,5,8-10) (Can have NONE of the following):   
        a. Absolute contraindication 
            1. Current back pain is not primarily due to the identified acute VCF(s). 
            2. Osteomyelitis, discitis or active systemic infection 
            3. Pregnancy 
            4. Greater than three vertebral fractures 
        b. Relative contraindication 
            1. Allergy to bone cement or opacification agents 
            2. Coagulopathy 
            3. Spinal instability 
            4. Myelopathy from the fracture 
            5. Neurologic deficit 
            6. Neural impingement 
            7. Fracture retropulsion/canal compromise 
 
*at least an acute component (e.g., acute on chronic) 
 
**consider including pedicle periosteal infiltration (7) 
 
You can find this information in the Local Coverage Determination (LCD):  Percutaneous Vertebral 
Augmentation (PVA) for Osteoporotic Vertebral Compression Fracture (VCF) (L33569). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that plans may choose the networks of providers available to enrollees and may require enrollees 
to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in 
the Medicare Managed Care Manual, Chapter 1, Section 20.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that outpatient mental health care requires prior authorization. You can see this on page 
77 of the 2020 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that MA plans may specify brands and manufacturers as preferred and charge lower cost-sharing 
for the preferred brands or may limit the DME to only those preferred brands and manufacturers, as long as the 
following conditions are met (42 CFR 422.100(l)): 
- The MA plan provides all categories of DME covered under original Medicare Part B; 
- The MA plan ensures that enrollees have access to all medically necessary (including non-preferred) 
DME products or brands; 
- The MA plan's contracted suppliers provide access to all preferred DME brands; 
- During an enrollee's first year of enrollment in an MA plan, if the enrollee requests, the plan will 
provide a 90-day transition period (commencing with the initial time of enrollment) during which the plan 
provides (and repairs, as applicable) non-preferred DME brands furnished in the previous year; 
- Although the MA plan may add brands to its preferred formulary during the year, it may not remove 
any brands mid-year; 
- The MA plan treats denials of non-preferred DME products or brands as organization determinations; 
- The MA plan discloses DME coverage limitations and appeal rights in the case of a denial of a non-
preferred DME product or brand with the EOC and ANOC and on its website; and 
- The MA plan provides full coverage, without limitation on brand and manufacturer, to DME categories 
or subcategories annually determined by CMS to require full coverage. 
 
You can find this rule at the Medicare Managed Care Manual, Chapter 4, Section 10.12.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract also says that they cover limited diabetic testing supplies (meter, strips, lancets) obtained through the 
pharmacy for a certain products. You can find this information on page 67 of the Plan's 2020 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare will not pay for dental services. Dental services are items and services involving 
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare 
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, 
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this 
rule in the SSA, Section 1862(a)(12) and Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes 
coverage for comprehensive oral evaluations once every 36 months. You can find this information on page 69 
of the Plan?s 2020 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that plans may choose the networks of providers available to enrollees and may require enrollees 
to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in 
the Medicare Managed Care Manual, Chapter 1, Section 20.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that, with limited exceptions, members of the Plan must use network providers to get medical care 
and services. The only exceptions are emergencies, urgently needed care when the network is not available 
(generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan 
authorizes the use of out-of-network providers. You can find this information on page 1-8 of the 2020 Evidence 
of Coverage.  
 
The Plan contract says that outpatient diagnostic services require prior authorization, and it is the responsibility 
of the provider to follow prior authorization rules. You can see this on page 4-33 of the 2020 Evidence of 
Coverage.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.The rules say that Medicare pays for care in a skilled nursing facility (SNF) when all of the following four factors are met:1. The patient requires skilled nursing or skilled rehabilitation services;2. The patient requires these services on a daily basis;3. As a practical matter, the daily skilled services can be provided only on an inpatient basis in a SNF; and4. The services are reasonable and necessary for the treatment of the patient's illness or injury or the services must be needed to establish a safe and effective maintenance program or to prevent the patient's condition from getting worse. You can find these rules at 42 CFR Section 409.31 and in the Medicare Benefit Policy Manual, Chapter 8, Section 30.  The rules say that custodial care is not covered. Custodial care is personal care for a person who does not need ongoing care fromtrained medical or paramedical staff. Custodial care serves to help with the activities of daily living. This means the care includes help in walking, getting in and out of bed, bathing, dressing, feeding, and using the toilet. Fixing meals and taking charge of medicine that usually can be self-administered are also custodial care services. You can find this rule in the Medicare Benefit Policy Manual, Chapter 16, Section 110.If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare will not pay for dental services. Dental services are items and services involving 
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare 
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, 
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this 
rule in the SSA, Section 1862(a)(12) and Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. Covered dental services are 
listed on pages 21-28 of the plan's 2020 Preventive & Comprehensive Dental Coverage Customer Handbook. 
Any service not listed is not covered.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that oral appliances generally are classified as dental devices and are not classified as durable 
medical equipment. The following items (not all-inclusive) are considered to be dental devices and will be 
denied as non-covered, not DME: 
 
   - Oral occlusal appliances used to treat temporomandibular joint (TMJ) disorders 
   - Tongue retaining devices used to treat OSA and/or snoring 
   - All oral appliances used only to treat snoring without a diagnosis of OSA 
   - Oral appliances used to treat other dental conditions 
   - Oral appliances that require repeated fitting and/or adjustments, beyond the first 90-days, in order to 
maintain fit and/or effectiveness. 
You can find this rule in the Local Coverage Article for Oral Appliances for Obstructive Sleep Apnea, A52512 
(eff 04/03/20). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare pays only for ambulance transport. Ambulance vehicles must be designed and 
equipped to meet certain requirements. The vehicle must have emergency warning lights, sirens, 
communications equipment, a stretcher, linens, emergency medical supplies, oxygen equipment and other life-
saving equipment. The vehicle also must be staffed with two people, one of whom is certified as an emergency 
medical technician. Medicare will not pay for transport by vehicles that do not meet these requirements. You 
can find this rule at 42 CFR Section 410.41. 
 
The rules say that plans may offer a supplemental benefit to provide transport not covered by original 
Medicare. The transport offered must be used only for the enrollee's health care needs, such as transport to the 
doctor's office. The transport must be arranged or directly provided by the health plan. The transport may not 
be used for other than health-related purposes. You can find this rule in the Medicare Managed Care Manual, 
Chapter 4, Section 30.3. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The health 
plan contract says covered services include: routine transportation for up to 36 one-way transportation trips per 
calendar year. You can find this information in Chapter 4 on page 4-68 of the plan's 2020 Evidence of 
Coverage.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.The rules say that Medicare pays only for ambulance transport. Ambulance vehicles must be designed and equipped to meet certain requirements. The vehicle must have emergency warning lights, sirens, communications equipment, a stretcher, linens, emergency medical supplies, oxygen equipment and other life-saving equipment. The vehicle also must be staffed with two people, one of whom is certified as an emergency medical technician. Medicare will not pay for transport by vehicles that do not meet these requirements. You can find this rule at 42 CFR Section 410.41.The rules say that plans may offer a supplemental benefit to provide transport not covered by original Medicare. The transport offered must be used only for the enrollee's health care needs, such as transport to the doctor's office. The transport must be arranged or directly provided by the health plan. The transport may not be used for other than health-related purposes. You can find this rule in the Medicare Managed Care Manual, Chapter 4, Section 30.3.If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.The Plan contract says that the Plan covers items andservices in accordance with Medicare rules. The contract says that the Plan covers routine, non-ambulance transportation as a supplemental (extra) benefit. This benefit covers 24 one-way trips to plan-approved locations every year. You can find this information on page 82 of the Plan's 2020 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare pays only for ambulance transport. Ambulance vehicles must be designed and 
equipped to meet certain requirements. The vehicle must have emergency warning lights, sirens, 
communications equipment, a stretcher, linens, emergency medical supplies, oxygen equipment and other life-
saving equipment. The vehicle also must be staffed with two people, one of whom is certified as an emergency 
medical technician. Medicare will not pay for transport by vehicles that do not meet these requirements. You 
can find this rule at 42 CFR Section 410.41. 
 
The rules say that plans may offer a supplemental benefit to provide transport not covered by original 
Medicare. The transport offered must be used only for the enrollee's health care needs, such as transport to the 
doctor's office. The transport must be arranged or directly provided by the health plan. The transport may not 
be used for other than health-related purposes. You can find this rule in the Medicare Managed Care Manual, 
Chapter 4, Section 30.3. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The health 
plan contract says covered services include: routine transportation for up to 60 one-way transportation trips per 
calendar year. Each one-way trip must not exceed 50 miles. A trip is considered one-way, a round trip is 
considered two trips. You can find this information in Chapter 4 on pages 4-47 to 4-48 of the plan's 2020 
Evidence of Coverage.