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 raised toilet seats are not covered because they are considered hygienic equipment that is not 
primarily medical in nature. You can find this rule in the Centers for Medicare and Medicaid Services, Internet 
Only Manual, Publication 100-03, Medicare National Coverage Determinations Manual, Section 280.1. 
 
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 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 the single photon emission computed tomograph (SPECT) acquires information on the 
concentration of radionuclides introduced into the patient's body. It is useful in the diagnosis of several clinical 
conditions including: 
 stress fracture. 
 spondylosis. 
 infection (e.g., discitis). 
 tumor (e.g., osteoid osteoma). 
 analyze blood flow to an organ, as in the case of myocardial viability. 
 differentiate ischemic heart disease from dilated cardiomyopathy. 
 
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-03, Medicare National Coverage Determination for Single Photon Emission Computed Tomography 
(SPECT), 220.12.  
 
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 a 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 and Medicaid Services, Internet Only Manual, National 
Correct Coding Initiative (NCCI) Manual, Chapter 10, Section F(8). 
 
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/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 and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual 
for Medicare Services, Chapter I(A). 
 
The rules say that code L5999 (lower extremity prosthesis, not otherwise specified) must not be used to bill for 
any features or functions included in the socket or addition codes. Use of L5999 is incorrect coding 
(unbundling). You can find this rule in the Local Coverage Article Lower Limb Prostheses - Policy Article 
A52496. 
 
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/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 and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual 
for Medicare Services, Chapter I(A). 
 
The rules say that For Medicare to consider coverage and payment for any item or service, the information 
submitted by the supplier or provider must corroborate the documentation in the beneficiarys medical 
documentation and confirm that Medicare coverage criteria have been met. You can find this rule in the 
Centers for Medicare & Medicaid Services, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.1. 
 
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.
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 XU modifier can be used to allow for separate payment of codes that would typically not 
be allowed for separate payment.  The XU modifier indicates and unusual non-overlapping Service, (the use of 
a service that is distinct because it does not overlap usual components of the main service). You can find this 
rule at Centers for Medicare and Medicaid Services, MLN Fact Sheet entitled "Proper Use of Modifiers 59, 
XE, XP, XS, and XU." 
 
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 Molecular Diagnostic Services Program (MolDX) will review all new test/assay clinical 
information to determine if a test meets Medicares reasonable and necessary requirement. Labs must submit a 
comprehensive dossier on each new test/assay prior to claim submission. MolDX will only cover and 
reimburse tests that demonstrate analytical and clinical validity, and clinical utility at a level that meets the 
Medicare reasonable and necessary requirement. This rule is found in Local Coverage Determination (LCD): 
MolDX: Molecular Diagnostic Tests (MDT) (L36256). 
 
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 pay for an inpatient rehabilitation facility (IRF) admission when the services 
are reasonable and medically necessary. The patient must require an intensive and coordinated interdisciplinary 
  
  
 approach to providing rehabilitation. The patient must need active and ongoing treatment by more than one 
therapy discipline. One of the therapies must be physical therapy or occupational therapy. The patient must 
need and be expected to actively participate in and to benefit from an intensive rehabilitation therapy program. 
This intensive rehabilitation therapy program generally consists of at least three hours of therapy per day at 
least five days per week. The patient does not need to be expected to achieve complete independence in self-
care nor be expected to return to his or her prior level of functioning. The patient must need supervision by a 
rehabilitation physician. The physician must see the patient at least three days per week throughout the stay. 
You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-02, Medicare Benefit Policy Manual, Chapter 1, Sections 110.2 and 110.2.5 and at 42 CFR Section 
412.622. 
 
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 A determination of the medical necessity for certain components/additions to the prosthesis 
is based on the beneficiarys potential functional abilities. Potential functional ability is based on the reasonable 
expectations of the prosthetist, and treating practitioner, considering factors including, but not limited to: 
 
The beneficiarys past history (including prior prosthetic use if applicable); and 
 
The beneficiarys current condition including the status of the residual limb and the nature of other medical 
problems; and 
 
The beneficiarys desire to ambulate. 
 
Clinical assessments of beneficiary rehabilitation potential must be based on the following classification levels: 
 
Level 0: Does not have the ability or potential to ambulate or transfer safely with or without assistance and a 
prosthesis does not enhance their quality of life or mobility. 
 
Level 1: Has the ability or potential to use a prosthesis for transfers or ambulation on level surfaces at fixed 
cadence. Typical of the limited and unlimited household ambulator. 
 
Level 2: Has the ability or potential for ambulation with the ability to traverse low level environmental barriers 
such as curbs, stairs or uneven surfaces. Typical of the limited community ambulator. 
 
Level 3: Has the ability or potential for ambulation with variable cadence. Typical of the community ambulator 
who has the ability to traverse most environmental barriers and may have vocational, therapeutic, or exercise 
activity that demands prosthetic utilization beyond simple locomotion. 
 
L5859 (ADDITION TO LOWER EXTREMITY PROSTHESIS, ENDOSKELETAL KNEE-SHIN SYSTEM, 
POWERED AND PROGRAMMABLE FLEXION/EXTENSION ASSIST CONTROL, INCLUDES ANY 
TYPE MOTOR(S)) is only covered when the beneficiary meets all of the criteria below:  
Has a microprocessor (swing and stance phase type (L5856)) controlled (electronic) knee 
 
K3 functional level only 
 
Has a documented comorbidity of the spine and/or sound limb affecting hip extension and/or quadriceps 
function that impairs K-3 level function with the use of a microprocessor-controlled knee alone 
 
Is able to make use of a product that requires daily charging 
 
Is able to understand and respond to error alerts and alarms indicating problems with the function of the unit 
 
If these coverage criteria for the knee component are not met, L5859 will be denied as not reasonable and 
necessary. 
 
You can find this information in the Local Coverage Determination (LCD) Lower Limb Prostheses L33787. 
 
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 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 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 Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, 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 34 of the Plans 2023 
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. 
 
Medicare may cover the use of an FDA-approved drug or biological if it is safe and effective and otherwise 
reasonable and necessary for the patient. Food and Drug Administration (FDA) approved drugs used for 
indications other than what is indicated on the official label may be covered if the use is determined to be 
medically accepted, taking into consideration the major drug compendia, authoritative medical literature and/or 
accepted standards of medical practice. You can find this rule in the Centers for Medicare and Medicaid 
Services (CMS), Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, 
Sections 50.4.1 and 50.4.2. 
 
The rules say that monoclonal antibodies directed against amyloid for the treatment of autonomic dysreflexia 
(AD) provided outside of a Food and Drug Administration (FDA) approved randomized controlled trial, CMS-
approved studies, or studies supported by the National Institutes of Health (NIH), are nationally non-covered. 
You can find this information in the National Coverage Determination (NCD) Monoclonal Antibodies Directed 
Against Amyloid for the Treatment of Alzheimer's Disease (AD) (200.3). 
 
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 ercutaneous vertebroplasty and percutaneous vertebral augmentation (PVA or Kyphoplasty) 
procedures will be considered medically reasonable and necessary for the following indications: 
 
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 (e.g. rest, bracing). 
 
Both PVP and 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 VCF (T1 L5), based on symptom onset, and 
documented by advanced imaging demonstrating bone marrow edema on MRI or bone-scan/SPECT/CT uptake 
and the beneficiary is symptomatic and is hospitalized with severe pain or is non-hospitalized with moderate to 
severe pain despite optimal non-surgical management (NSM) with one of the following. Worsening Pain or 
stable to improved pain when two or more of the following are present. Progression of vertebral body height 
loss, greater than 25% vertebral body height reduction, kyphotic deformity, or severe impact of VCF on daily 
functioning. 
 
Malignant Vertebral Fractures Osteolytic vertebral metastasis or myeloma with severe back pain related to a 
destruction of the vertebral body, not involving a major part of the cortical bone. You can find this rule in the 
Local Coverage Determination (LCD) L35130: Percutaneous Vertebral Augmentation (PVA) for Vertebral 
Compression Fracture (VCF). 
 
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 may cover a drug or biological if it is safe and effective and otherwise reasonable 
and necessary. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 50.4.1. 
  
Medicare rules also allow the plan to use step therapy. This is the process of beginning drug therapy for a 
medical condition with "preferred" (or more cost-effective) on-formulary drug alternative(s) and progressing to 
other drug therapies only as necessary. A plan must grant an exception to its step therapy rules if it determines 
that the requested drug is medically necessary, consistent with the prescriber's statement. The statement must 
show that the step therapy drugs: have been ineffective in treating the enrollee; or are likely to be ineffective or 
adversely affect the drug's effectiveness or patient compliance; or are likely to cause an adverse reaction or 
other harm to the enrollee.  
 
Medicare Advantage plans should ensure that new step therapy requirements do not disrupt ongoing Part B 
drug therapies for enrollees. Step therapy may only be applied to new prescriptions or administrations of Part B 
drugs for enrollees that are not actively receiving the affected medication. You can find this information at 42 
CFR Sections 422.2 and 422.136. 
 
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 has step therapy requirements for certain Medicare Part B covered drugs/biologicals. 
Enrollees may be required to try a preferred drug before the Plan will approve the requested medication. You 
can find this information on page 114 of the Plan's 2023 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 A non-spinal electrical osteogenesis stimulator (E0747) is covered only if any of the 
following criteria are met: 
 
1. Nonunion of a long bone fracture (see Appendices section) defined as radiographic evidence that fracture 
healing has ceased for three or more months prior to starting treatment with the osteogenesis stimulator, or 
2. Failed fusion of a joint other than in the spine where a minimum of nine months has elapsed since the last 
surgery, or 
3. Congenital pseudarthrosis. 
 
The appendices section notes that a long bone is limited to a clavicle, humerus, radius, ulna, femur, tibia, 
fibula, metacarpal, or metatarsal. You can find this information in the Local Coverage Determination (LCD): 
Osteogenesis Stimulators (L33796). 
 
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 for an oral anticancer drug to be covered, all of the following criteria (1-4) must be met:                                               
1. It is a drug or biological that has been approved by the Food and Drug Administration (FDA), and 
2. It has the same active ingredients as a non-self-administrable anticancer chemotherapeutic drug or 
biological that is covered when furnished incident to a practitioners service. The oral anticancer drug 
and the non-self-administrable drug must have the same chemical/generic name as indicated by the 
FDA's Approved Drug Products (Orange Book), Physician's Desk Reference (PDR), or an authoritative 
drug compendium, or it is a prodrug which, when ingested, is metabolized into the same active 
ingredient which is found in the non-self-administrable form of the drug, and 
3. It is used for the same anticancer chemotherapeutic indications, including unlabeled or off label 
uses, as the non-self-administrable form of the drug, and 
4. It is prescribed by a practitioner licensed under state law to prescribe such drugs as anticancer 
chemotherapeutic agents. 
 
A drug that is not available in an injectable form does not meet criterion 2. If an oral anticancer drug is used for 
immunosuppression (rather than the treatment of cancer), criterion 3 is not met, and the drug cannot be covered 
under the oral anticancer drug benefit. If the drug is used for immunosuppression following organ transplant, 
refer to the Immunosuppressive Drugs policy. 
 
If criteria 1-4 are not met, the drug will be denied as non-covered. You can find these rules in Medicare Claims 
Processing Manual Chapter 17, Sections 80.1 and 80.3. 
 
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.