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 Medicare Advantage (MA) plans may specify brands and manufacturers as preferred and 
charge lower cost-sharing for the preferred brands or may limit the durable medical equipment (DME) to only 
those preferred brands and manufacturers, as long as they ensure that enrollees have access to all medically 
necessary (including non-preferred) DME products or brands. You can find this information in the Centers for 
Medicare and Medicaid Services Internet Only Manual, Publication 100-16, Medicare Managed Care Manual 
Chapter 4, 10.12.2. 
 
The rules say that a health plan must disclose to its enrollees, in clear accurate terms, the benefits offered under 
a plan, including applicable conditions and limitations, premiums and cost-sharing, and any other conditions 
associated with receipt or use of benefits. You can find this rule at 42 CFR Section 422.111(a) and (b). 
 
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 the Plan generally covers any durable medical equipment (DME) covered by 
Original Medicare from the brands and manufacturers on the list provided with your Evidence of Coverage. 
The list tells you the brands and manufacturers of DME that the plan will cover. The Plan will not cover other 
brands and manufacturers unless your doctor or other provider tells us that the brand is appropriate for your 
medical needs. You can find this information on page 56 of the Plan's 2023 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 to be eligible for coverage of a continuous glucose monitor (CGM) and related supplies, the 
beneficiary must meet all of the following initial coverage criteria (1)-(5): 
 
1. The beneficiary has diabetes mellitus; and, 
2. The beneficiarys treating practitioner has concluded that the beneficiary (or beneficiarys caregiver) has  
    sufficient training using the CGM prescribed as evidenced by providing a prescription; and, 
3. The CGM is prescribed in accordance with its Food and Drug Administration (FDA) indications for use;  
    and, 
4. The beneficiary for whom a CGM is being prescribed, to improve glycemic control, meets at least one of the  
    criteria below: 
      A. The beneficiary is insulin-treated; or, 
      B. The beneficiary has a history of problematic hypoglycemia with documentation of at least one of the  
           following: 
           -     Recurrent level 2 hypoglycemic events that persist despite multiple attempts to adjust  
                 medication(s) and/or modify the diabetes treatment plan; or, 
           -     A history of one level 3 hypoglycemic event characterized by altered mental and/or physical state  
                 requiring third-party assistance for treatment of hypoglycemia 
5. Within six (6) months prior to ordering the CGM, the treating practitioner has an in-person or Medicare- 
     approved telehealth visit with the beneficiary to evaluate their diabetes control and determined that criteria  
     (1)-(4) above are met.  
 
You can find this information in the Local Coverage Determination (LCD): Glucose Monitors (L33822). 
 
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 Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-02, 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 does not include 
complete maxillary/mandibular overdentures, endosteal implants, or custom fabricated abutments. You can 
find this information on pages 61-62 of the Plans 2023 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 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). 

The rules say that non covered services include blanket orders, reflex definitive urine drug testing (UDT) is not 
reasonable and necessary when presumptive testing is performed at point of care because the physician may 
have sufficient information to manage the patient. If the clinician is not satisfied, he/she must determine the 
clinical appropriateness of and order specific subsequent definitive testing (e.g., the patient admits to using a 
particular drug, or the immunoassay (IA) cut-off is set at such a point that is sufficiently low that the physician 
is satisfied with the presumptive test result), routine standing orders for all patients in a physician's practice are 
not reasonable and necessary. You can find the rules in Local Coverage Determination (LCD) Controlled 
Substance Monitoring and Drugs of Abuse Testing L36393. 

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 Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-02, 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 specific dental items/services stated in the Plans contract. You can find this information on pages 
83-87 of the Plans 2023 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 providers/suppliers must report services correctly. Procedures should be reported with the 
Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in 
the Centers for Medicare & Medicaid Services, Medicare National Correct Coding Initiative Policy Manual for 
Medicare Services, Chapter I(A). 
 
The rules say that all services integral to accomplishing a procedure are considered bundled into that procedure 
and, therefore, are considered a component part of the comprehensive code. Many of these generic activities 
are common to virtually all procedures and, on other occasions, some are integral to only a certain group of 
procedures but are still essential to accomplish these particular procedures. Accordingly, it is inappropriate to 
separately report these services based on standard medical and surgical principles. You can find this rule in the 
Centers for Medicare & Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims 
Processing Manual, Chapter 12, Section 30.A. 
 
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 percutaneous vertebroplasty (PVP) and percutaneous vertebral augmentation (PVA or 
Kyphoplasty) procedures will be considered medically reasonable and necessary for the following indications: 
 
1. Painful, debilitating, osteoporotic vertebral collapse/compression fractures, defined as those that have not 
responded to non-surgical medical management with and without methods of immobility. 
 
Both percutaneous vertebroplasty (PVP) and percutaneous vertebral augmentation (PVA) will be considered 
reasonable and necessary when ALL of the following criteria are met: 
- Acute (less than 6 weeks) or subacute (6-12 weeks) osteoporotic vertebral compression fracture (VCF) (T1- 
L5), based on symptom onset, and documented by advanced imaging demonstrating bone marrow edema on 
magnetic resonance imaging (MRI) or bone-scan/Single-Photon Emission Computerized Tomography 
(SPECT)/computed tomography (CT) uptake and 
- The beneficiary is symptomatic and is hospitalized with severe pain (Numeric Rating Scale [NRS] or Visual 
Analog Scale [VAS] pain score greater than or equal to 8) or is non-hospitalized with moderate to severe pain 
(NRS or VAS greater than or equal to 5) despite optimal non-surgical management (NSM) with one of the 
following: 
Worsening Pain or 
Stable to improved pain (but NRS or VAS greater than or equal to 5) when 2 or more of the following are 
present: 
- Progression of vertebral body height loss 
- greater than 25% vertebral body height reduction 
- Kyphotic deformity 
- Severe impact of VCF on daily functioning (Roland Morris Disability Questionnaire [RDQ] greater than 17) 
 
You can find this information in the Local Coverage Determination (LCD): Percutaneous Vertebral 
Augmentation (PVA) for Vertebral Compression Fracture (VCF) (L34976). 
 
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 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. If no code accurately describes the procedure performed, the laboratory may report Current Procedural 
Terminology (CPT) code 81479 (Unlisted molecular pathology procedure) with one unit of service. You can 
find this information in the Centers for Medicare & Medicaid Services, Internet Only Manual, National Correct 
Coding Initiative (NCCI) Manual, Chapter 10, Section F(8). 
 
 The rules say that providers/suppliers must report services correctly. Procedures should be reported with the 
Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in 
the Centers for Medicare & Medicaid Services, Medicare National Correct Coding Initiative Policy Manual for 
Medicare Services, Chapter I(A). 
 
The rules say that clinical diagnostic laboratory tests (CDLTs) making use of high throughput technologies (as 
defined in this Ruling) and administered during the ongoing emergency period defined in paragraph (1)(B) of 
section 1135(g) of the Act beginning on or after March 18, 2020, for the detection of SARSCoV2 or the 
diagnosis of the virus that causes Covid19, are new and involve high throughput machines (which are highly 
sophisticated equipment) which require more intensive technician training (to ensure the role of extremely 
skilled personnel) and more time intensive processes (to assure quality). These tests are a type of CDLT 
currently paid for under Medicare Part B using codes U0003 and U0004. You can find this rule in the Centers 
for Medicare & Medicaid Services, Ruling Number CMS-2020-01-R. 
 
The rules say that beginning January 1, 2021, CMS will establish a new add-on payment of $25 as identified by 
HCPCS code U0005. As required by the HCPCS code U0005 descriptor, this add-on payment may be billed 
with either HCPCS code U0003 or HCPCS code U0004 when the applicable test is completed within 2 
calendar days of the specimen being collected. You can find this ruling in the Centers for Medicare & Medicaid 
Services, Ruling Number CMS-2020-1-R2. 
 
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 Centers for Medicare and Medicaid Service (CMS) has established units of service edits 
referred to as Medically Unlikely Edits (MUEs). An MUE for a Healthcare Common Procedure Coding System 
(HCPCS)/Current Procedural Terminology (CPT) code is the maximum number of units of service under most 
circumstances allowable by the same provider for the same enrollee on the same date of service. Claims 
submitted where the unit of service exceeds the MUE value for that HCPCS/CPT code will be denied. 
 
Beginning on April 1, 2013, CMS introduced the MUE Adjudication Indicator (MAI) to differentiate between 
types of MUEs. If a code has an MAI of 1, appropriate use of a modifier may be used to report the same code 
on separate lines of the claim. MUEs for codes with an MAI of 2 are absolute date of service edits. These are 
per day edits based on policy. MUEs for codes with an MAI of 3 are per day edits based on clinical 
benchmarks. Codes with an MAI of 3 are based on criteria combined with data such that it would be 
possible, but medically unlikely, that higher values would represent correctly reported medically necessary 
services. To be paid, there must be evidence (e.g., medical review) that the excess units were actually provided, 
were correctly coded, and were medically necessary. 
 
You can find this rule in the Centers for Medicare & Medicaid Services, Medicare National Correct Coding 
Initiative Policy Manual for Medicare Services, Chapter I(V). 
 
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 Plan 
contract says that enrollees must pay a $100 copayment for Medicare-covered diagnostic test and procedures at 
an outpatient hospital setting. You can find this information on page 83 of the Plan's 2023 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 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 Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
The rules say that Medicare plans must make reasonable and diligent efforts to gather and forward information 
to the Independent Review Entity (IRE). You can find this information in the Centers for Medicare and 
Medicaid Services, Internet Only Manual, Parts C & D Enrollee Grievances, Organization/Coverage 
Determinations, and Appeals Guidance Manual, Section 50.12.1. 
 
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 the 
requested item or service but is limited to 1 procedure code per plan year. You can find this information on 
pages 75-78 and 82-85 of the Plan's 2023 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 Guardant360 remains covered for patients with non-CNS originated solid tumors who meet
the criteria of NCD 90.2 when the following conditions are met: Patient has been diagnosed with a recurrent,
relapsed, refractory, metastatic, or advanced solid tumor that did not originate from the central nervous system.
Patients who would meet all of the indications on the FDA label for larotrectinib if they are found to have an
NTRK mutation may be considered to have advanced cancer, and Patient has not previously been tested with
the Guardant360 test for the same primary cancer. For a patient who has been tested previously using
Guardant360 for a cancer, that patient may only be tested again when the patient has a new primary cancer
diagnosis. In a patient with previously tested primary cancer, who has evidence of new malignant growth, that
growth may be considered to be a different primary cancer if it does not originate from the same cell line or it
is physiologically different enough that it responds differently to treatment than the previously tested cancer,
and Patient is untreated for the primary cancer being tested or the patient is not responding to treatment (e.g.
progression or new lesions on treatment), and the patient has decided to seek further cancer treatment with the
following conditions: The patient is a candidate for further treatment with a drug that is either FDA-approved
for that patient's cancer, or has an NCCN 1 or NCCN 2A recommendation for that patient's cancer, and
The FDA-approved indication or NCCN recommendation is based upon information about the presence or
absence of a genetic biomarker tested for in the Guardant360 assay, and Tissue-based CGP is infeasible (i.e.,
quantity not sufficient for tissue-based CGP or invasive biopsy is medically contraindicated) or specifically in
NSLC Tissue-based CGP has shown no actionable mutations. You can find this in the Medicare Local
Coverage Article (LCA) Billing and Coding: Guardant 360 (A58192).

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.