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 state that coverage and payment for Medicare telehealth services includes consultation, office visits, 
individual psychotherapy, and pharmacologic management delivered via a telecommunications system. 
Eligible geographic areas include rural health professional shortage areas (HPSA) and counties not classified as 
a metropolitan statistical area (MSA). The originating site for telehealth services (location to which the enrollee 
presents) must be a practitioner?s office, hospital, rural health clinic (RHC), federally qualified health center 
(FQHC), skilled nursing facility or community mental health center. You can find this rule in the Medicare 
Claims Processing Manual, Chapter 12, Sections 190.1 and 190.2. 
  
The rules say that for eligible telehealth services, telecommunications systems substitute for an in-person 
encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an originating 
site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional 
Shortage Area (HPSA) located in a rural census tract. You can find this in the CMS MLN document entitled 
"Telehealth Services."
 
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 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  analyzes tumor-derived cell-free DNA (also known as ctDNA) to detect 
somatic alterations that, in conjunction with standard clinical assessment, can guide treatment decisions in the 
following intended use population: patients with Stage IIIB/IV NSCLC. To report a service for 
NSCLC, please submit the following claim information: 
- Enter 1 unit of service (UOS) 
- Enter the appropriate DEX Z-Code? identifier adjacent to the CPT? code in the comment/narrative 
field for the Part B claim field/types 
- CPT/HCPCS Codes: 81479 
You can find this rule in the Local Coverage Determination and Article for MolDX: Plasma-
Based Comprehensive Genomic Profiling in Non-Small Cell Lung Cancer (NSCLC) L37649 and A57425 (eff 
prior to 05/14/20). 
 
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. 
 
Medicare guidance says ?For any DMEPOS item to be covered by Medicare, the patient?s medical record must 
contain sufficient documentation of the patient?s medical condition to substantiate the necessity for the type 
and quantity of items ordered and for the frequency of use or replacement (if applicable). The information 
should include the patient?s diagnosis and other pertinent information including, but not limited to, duration of 
the patient?s condition, clinical course (worsening or improvement), prognosis, nature and extent of functional 
limitations, other therapeutic interventions and results, past experience with related items, etc. If an item 
requires a CMN or DIF, it is recommended that a copy of the completed CMN or DIF be kept in the patient?s 
record. However, neither a physician?sorder nor a CMN nor a DIF nor a supplier prepared statement nor a 
physician attestation by itself provides sufficient documentation of medical necessity, even though it is signed 
by the treating physicianor supplier. There must be information in the patient?s medical record that supports the 
medical necessity for the item and substantiates the answers on the CMN (if applicable) or DIF (if applicable) 
or information on a supplier prepared statement or physician attestation (if applicable)?. 
Also,?Beforesubmitting a claim to the DME MAC the supplier must have on file a dispensing order, the 
detailed written order, the CMN (if applicable), the DIF (if applicable), information from the treating physician 
concerning the patient's diagnosis, and any information required for the use of specific modifiers or attestation 
statements as defined in certain DME MAC policies. The supplier should also obtain as much documentation 
from the patient's medical record as they determine they need to assure themselves that coverage criteria for an 
item have been met. If the information in the patient's medical record does not adequately support the medical 
necessity for the item, the supplier is liable for the dollar amount involved unless a properly executed ABN of 
possible denial has been obtained.?. You can find this guidance in the Medicare Program Integrity Manual, 
Chapter 5 - Items and Services Having Special DME Review Considerations, Section 5.7 ? Documentation in 
the Patient?s Medical Record and Section 5.8 - Supplier Documentation. 
 
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 Appeal Number is: 
1-9433341901 
 
The rules say that an inpatient admission is generally appropriate when the admitting physician expects the 
patient to need hospital care that crosses at least two midnights. The expectation should be based on such 
complex medical factors as medical history, the severity of signs and symptoms, current medical needs, and 
medical risk. The factors must be documented in the medical record. The order for inpatient admission must be 
present in the medical record.  
 
If an unforeseen event, such as a patient's death or transfer, results in a shorter stay, the patient may be 
considered to be treated as an inpatient. An inpatient admission for a surgical procedure listed by Medicare as 
?inpatient only? is generally appropriate, regardless of the length of stay. An inpatient admission may be 
appropriate if the admitting physician expects a patient to require hospital care for only a limited period of 
time. The decision to admit as an inpatient must be based on the clinical judgment of the physician and must be 
supported by the medical record. You can find this rule at 42 CFR Section 412.3. 
 
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.
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 Plan contract includes a list of covered supplemental dental services. The contract specifically says that any procedure not listed is not covered. Application of desensitizing medicament (D9910) and unspecified adjunctive procedure (D9999) are not included on this list and are not covered supplemental benefits. You can find this information on pages 4-73 to 4-77 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 state that to report a Guardant360 service, please submit the following claim information: 
Enter 1 unit of service (UOS) 
Enter the appropriate DEX Z-Code identifier adjacent to the Current Procedural Terminology (CPT) 
code 81479 in the comment/narrative field for the following Part B claim field/types: 
o Loop 2400 or SV101-7 for the 5010A1 837P 
o Item 19 for paper claim 
Enter the appropriate DEX Z-Code identifier adjacent to the CPT code 81479 in the comment/narrative 
field for the following Part A claim field/types: 
o Line SV202-7 for 837I electronic claim 
o Block 80 for the UB04 claim form 
? Select the appropriate ICD-10-CM code 
 
You can find this rule in Local Coverage Article (LCA) Billing and Coding: MolDX: Guardant360 Plasma-
Based Comprehensive Genomic Profiling in Non-Small Cell Lung Cancer (NSCLC) (A57425). 
 
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 CMS Correct Coding Initiative (CCI) has identified column I procedure codes and their
associated column II procedure codes based on the principles of correct coding. Services that are considered
column II procedures to another service are not eligible for reimbursement when billed with the column I
procedure code. You can find this information in Medicare's CMS Correct Coding Initiative (CCI).
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 a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information 
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and 
(b). 
 
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say 
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to 
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2. 
 
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 health 
plan contract says that enrollees must pay a $75 copayment for each Medicare-covered radiological diagnostic 
service, not including X-rays, performed in a physician?s office or at a free-standing facility. You can find this 
information in Chapter 4 on page 4-30 of the plan's 2019 Evidence of Coverage. 
 
The health plan contract says that enrollees must pay a $30 copayment for services obtained from a specialist, 
or under certain circumstance, treatment by a nurse practitioner or physician's assistance or other non-
physician health care professionals in a specialist?s office (as permitted under Medicare rules). You can find 
this information in Chapter 4 on page 4-38 of the plan's 2019 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 state that L33829 - Pneumatic Compression Device; 1/1/20 
 
A PCD coded as E0650 or E0651 is covered for both primary and secondary lymphedema in beneficiaries with 
chronic and severe lymphedema when all of the following three requirements are met: 
1. The beneficiary has a diagnosis of lymphedema as defined above, and 
2. The beneficiary has persistence of chronic and severe lymphedema as identified by the documented presence 
of at least one of the following clinical findings: 
       - Marked hyperkeratosis with hyperplasia and hyperpigmentation, 
       - Papillomatosis cutis lymphostatica, 
       - Deformity of elephantiasis, 
       - Skin breakdown with persisting lymphorrhea, 
       - Detailed measurements over time confirming the persistence of the lymphedema with a history 
evidencing a likely etiology, and 
3. In addition to this documented persistence, the lymphedema is then documented to be unresponsive to other 
clinical treatment over the course of a required four-week trial. 
 
A PCD coded as E0652, is covered for the treatment of lymphedema extending onto the chest, trunk and/or 
abdomen when all of the following are met: 
   - The beneficiary has lymphedema of an extremity as defined above 
   - The coverage criteria for an E0650 or E0651 are met 
   - The beneficiary has lymphedema extending onto the chest, trunk and/or abdomen that extends past the 
limits of a standard compression sleeve, and the chest, trunk and/or abdominal lymphedema has failed to 
improve with a four-week trial. 
 
PCDs coded as E0650, E0651, E0652 are used only in the treatment of lymphedema or for the treatment of 
chronic venous insufficiency with venous stasis ulcers. A PCD coded as E0650 or E0651 used to treat edema 
from causes other than lymphedema is not eligible for reimbursement. Claims will be denied as not reasonable 
and necessary. A PCD coded as E0652 is not covered for the treatment of lymphedema of the extremities alone 
even if the criteria in this section are met. Claims will be denied as not reasonable and necessary. A PCD coded 
as E0652 used to treat lymphedema not extending onto the chest, trunk and/or abdomen or CVI is not eligible 
for reimbursement. Claims will be denied as not reasonable and necessary. You can find this rule in the Local 
Coverage Determination for Pneumatic Compression Devices, L33829 (eff 01/01/20). 
 
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 state that the indications for surgical treatment of varicose veins of the lower extremities are: 
1. A 3-month trial of conservative therapy such as exercise, periodic leg elevation, weight loss, 
compressive therapy, and avoidance of prolonged immobility where appropriate, has failed, AND 
2. The patient is symptomatic and has one, or more, of the following: 
a. Pain or burning in the extremity severe enough to impair mobility 
b. Recurrent episodes of superficial phlebitis 
c. Non-healing skin ulceration 
d. Bleeding from a varicosity 
e. Stasis dermatitis 
f. Refractory dependent edema 
 
You can find these rules in Local Coverage Determination (LCD) Treatment of Varicose Veins of the Lower 
Extremities (L34209). 
 
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 state that Continued coverage of a PAP device (E0470 or E0601) beyond the first three months of 
therapy requires that, no sooner than the 31st day but no later than the 91st day after initiating therapy, the 
treating practitioner must conduct a clinical re-evaluation and document that the beneficiary is benefiting from 
PAP therapy. 
For PAP devices with initial dates of service on or after November 1, 2008, documentation of clinical benefit is 
demonstrated by: 
1. In-person clinical re-evaluation by the treating practitioner with documentation that symptoms of obstructive 
sleep apnea are improved; and 
2. Objective evidence of adherence to use of the PAP device, reviewed by the treating practitioner. 
 
Adherence to therapy is defined as use of PAP &#8805;4 hours per night on 70% of nights during a consecutive thirty 
(30) day period anytime during the first three (3) months of initial usage. 
 
If the above criteria are not met, continued coverage of a PAP device and related accessories will be denied as 
not reasonable and necessary. 
 
You can find these rules in the Local Coverage Determination (LCD) for Positive Airway Pressure (PAP) 
Devices for the Treatment of Obstructive Sleep Apnea, L33718. This LCD is effective for services provided on 
or after January 1, 2020. 
 
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 the Guardant360 panel must be billed with procedure code 81479. You can find this rule at 
Local Coverage Determination (LCD): MolDX: Plasma-Based Comprehensive Genomic 
Profiling in Non-Small Cell Lung Cancer (NSCLC) (L37649) (eff. 11/1/19). 
 
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 a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information 
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and 
(b). 
 
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say 
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to 
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2. 
 
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 contract 
with the Plan says that enrollees have a $0 copayment for Medicare-covered laboratory services. You can find 
this information on page 79 of the plan's 2020 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 medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that services that are not medically necessary are not covered. The rules also say that 
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 
411.15(o). 
 
Medicare rules say that effective for services provided on/after April 1, 2008 , E0118, crutch substitute, lower 
leg platform, with or without wheels, each, sometimes referred to as a Roll-A-Bout, will be denied not 
medically necessary and will be denied as supplier liable. You can find these rules in the DME MAC Article 
entitled "PLATFORM CRUTCH CLARIFICATION". 
 
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 state that either intraarticular injections or medial branch blocks may provide temporary or long-
lasting or permanent relief of facet-mediated pain. Injections may be repeated if the first injection results in 
significant pain relief (>50%) for at least 3 months. (See Limitations section for total number of injections that 
may be performed in one year.) 
 
You can find this information in the Local Coverage Determination (LCD):  Facet Joint Injections, Medial 
Branch Blocks, and Facet Joint Radiofrequency Neurotomy (L35936). 
 
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 enteral nutrition is considered reasonable and necessary for a patient with a functioning 
gastrointestinal tract who, due to pathology to, or non-function of, the structures that normally permit food to 
reach the digestive tract, cannot maintain weight and strength commensurate with his or her general condition. 
Nutritional supplements are often given as a medicine between meals to boost protein-caloric intake or the 
mainstay of a daily nutritional plan. Medicare does not pay for nutritional supplements. You can find this rule 
in the Medicare National Coverage Determination Manual, Chapter 1, Section 180.2. 
 
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.