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 the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or 
carrier sufficient information to determine whether payment is due and the amount of payment. You can find 
this rule at 42 CFR 424.5. 
 
The rules say 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 beneficiary's medical 
documentation and confirm that Medicare coverage criteria have been met. You can see this in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Publication 100-08, Medicare Program Integrity 
Manual Chapter 3, 3.3.2.1. 
 
The rules state that therapeutic continuous glucose monitors (CGMs) and related supplies are covered by 
Medicare when all of the following coverage criteria are met: 
  1. The beneficiary has diabetes mellitus, 
  2. The beneficiary has been using a blood glucose monitor (BGM) and performing frequent (four or more 
times a day) testing, 
  3. The beneficiary is insulin-treated with multiple (three or more) daily injections of insulin or a Medicare-
covered continuous subcutaneous insulin infusion (CSII) pump, 
  4. The beneficiarys insulin treatment regimen requires frequent adjustment by the beneficiary on the basis of 
BGM or CGM testing results. 
  5. Every six (6) months following the initial prescription of the CGM, the treating practitioner has an in-
person visit with the beneficiary to assess adherence to their CGM regimen and diabetes treatment plan. 
 
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 a Medicare plan may restrict members to a network of providers as long as medically 
necessary covered care is accessible and available through this network. The rules say that the Plan must 
arrange for specialty care outside of the Plan provider network when network providers are unavailable or 
inadequate to meet a member's medical needs. You can find this rule at 42 CFR Section 422.112(a)(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 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 86 of the Plan's 2022 
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 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 pages 43-45 and 50-51.
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). 
 
For purposes of payment under the Medicare Physician Fee Schedule (MPFS), the Place of Service (POS) code 
is generally used to reflect the actual setting where the beneficiary receives the face-to-face service. However, 
there are two exceptions to this general rule  these are for a service rendered to a patient who is a registered 
inpatient or an outpatient of a hospital. In these cases, the correct POS code - regardless of where the face-to-
face service occurs - is that of the appropriate inpatient POS code (at a minimum POS code 21) or that of the 
appropriate outpatient hospital POS code (at a minimum POS code 19 or 22, for outpatient services performed 
off campus or on campus). So, if in the above example, the patient seen in the physicians office is actually an 
inpatient of the hospital, POS code 21, for inpatient hospital, is correct. In this example, the POS code reflects a 
different setting than the address and ZIP code of the practice location (the physicians office). You can find 
this information in the Centers for Medicare and Medicaid Services Internet-Only Manual, Publication 100-04, 
Medicare Claims Processing Manual, Chapter 26, Section 10.6. 
 
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 provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or 
carrier sufficient information to determine whether payment is due and the amount of payment. You can find 
this rule at 42 CFR 424.5. 
 
The rules say 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 beneficiary's medical 
documentation and confirm that Medicare coverage criteria have been met. You can see this in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Publication 100-08, Medicare Program Integrity 
Manual Chapter 3, 3.3.2.1. 
 
The rules say that 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. You can find this 
rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-08, Medicare 
Program Integrity Manual, Chapter 5, Section 5.7. 
 
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 Guardant360 testing is covered only when all of the following conditions are met: 
1. 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 Food and Drug Administration (FDA) label for larotrectinib if they are found to have a neurotrophic 
receptor tyrosine kinase (NTRK) mutation may be considered to have advanced cancer, and 
2. Patient has not previously been tested with the Guardant360 test for the same genetic content. For a 
patient who has been tested previously using Guardant360 for cancer, that patient may not be tested 
again unless there is clinical evidence that the cancer has evolved wherein testing would be performed 
for a different genetic content. Specifically, in patients with previously tested cancer, who have 
evidence of new malignant growth, despite response to a prior targeted therapy, that growth may be 
considered to be sufficiently genetically different to require additional genetic testing, and 
3. Patient is untreated for the cancer being tested or the patient is not responding to treatment (e.g. 
progression or new lesions on treatment), and 
4. The patient has decided to seek further cancer treatment with the following conditions:  
A. The patient is a candidate for further treatment with a drug that is either FDA-approved for that 
patients cancer, or has a National Comprehensive Cancer Network (NCCN) or NCCN 2A 
recommendation for that patients cancer, and 
B. 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 
5. Tissue-based, comprehensive genomic profiling (CGP) is infeasible (e.g., 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 more information in Local Coverage Determination (LCD): MolDX: Plasma-Based Genomic 
Profiling in Solid Tumors. 
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 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 51 of the Plan's 2022 
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 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: 
 
 
1. The beneficiarys past history (including prior prosthetic use if applicable); and 
2. The beneficiarys current condition including the status of the residual limb and the nature of other medical 
problems; and 
3. The beneficiarys desire to ambulate. 
You can find this rule in Local Coverage Determination (LCD): Lower Limb Prostheses (L33787) - Effective 
January 1, 2020. 
 
The rules say that a level 3 ambulator 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. You 
can find this rule in Local Coverage Determination (LCD): Lower Limb Prostheses (L33787) - Effective 
January 1, 2020. 
 
The rules say that a flex-walk system or equal (L5981) is covered for beneficiaries whose functional level is 3 
or above. You can find this rule in Local Coverage Determination (LCD): Lower Limb Prostheses (L33787) - 
Effective January 1, 2020. 
 
The rules say that coverage is extended only if there is sufficient clinical documentation of functional need for 
the technologic or design feature of a given type of foot. This information must be retained in the treating 
practitioner's or prosthetist's files. You can find this rule in the Local Coverage Determination (LCD) - Lower 
Limb Prostheses (L33787) - Effective 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 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 Medicare Part B pays for outpatient physical therapy services only if they are furnished by, 
or under the direct supervision of a physical therapist in private practice; or by, or incident to the service of a 
nurse practitioner (NP) or physician assistant (PA) only when that NP/PA may perform physical therapy 
services under State law. You can find this information in Title 42 CFR Section 410.60. 
 
The rules say that beginning in July 2015, claims for compounded drugs shall be submitted using a 
compounded drug, not otherwise classified (NOC) code. You can find this information in the Centers for 
Medicare and Medicaid Service, Internet-Only Manual, Medicare Claims Processing Manual, Chapter 17, 
Section 20.1.2. 
 
The rules say that Modifier 25 is defined as a significant, separately identifiable Evaluation and Management 
(EM) service by the same physician or other qualified health care professional on the same day of a procedure 
or other service. You can find this in the article Modifier 25 Fact Sheet on the Novitas Solutions website at 
https://www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00097341. 
 
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 to qualify for the Medicare home health benefit, under Section 1814(a)(2)(C) and 
1835(a)(2)(A) of the Act, a Medicare beneficiary must meet the following requirements: 
Be confined to the home; 
Under the care of a physician or allowed practitioner; 
Receiving services under a plan of care established and periodically reviewed by a physician or allowed 
practitioner; 
Be in need of skilled nursing care on an intermittent basis or physical therapy or speech-language pathology; or 
Have a continuing need for occupational therapy. You can find this information in the Medicare Benefit Policy 
Manual, Chapter 7; Home Health Services, 30 - Conditions Patient Must Meet to Qualify for Coverage of 
Home Health 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 state that non-coverage reaffirmed for CPT code 0012M for CxBladder.  
You can find these rules in the Local Coverage Determination (LCD) for Biomarkers for Oncology,L35396. 
 
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 following must be documented in order to cover mastectomy for gynecomastia: 
 
1. Glandular breast tissue confirming true gynecomastia is documented on physical exam and/or 
mammography. 
2. Documentation that the gynecomastia persists, despite correction of any underlying causes. 
3. Documentation supporting that the gynecomastia is classified as Grade III or IV per the American Society of 
Plastic Surgeons (ASPS) classification when the procedure is performed in males. 
4. Documentation that hormonal causes, including hyperthyroidism, estrogen excess, hyperprolactinemia and 
hypogonadism have been excluded by appropriate laboratory testing (e.g., with levels of thyroid stimulating 
hormone [TSH], estradiol, prolactin, testosterone and/or luteinizing hormone [LH]) 
5. Documentation supporting that gynecomastia persists after 3 to 4 months of unsuccessful medical treatment, 
the use of potential gynecomastia-inducing drugs and substances has been ruled out and gynecomastia persists 
for at least one year. 
 
You can find this rule in the Local Coverage Article (LCA) - Billing and Coding: Cosmetic and Reconstructive 
Surgery (A56587) - Effective July 11, 2021. 
 
The rules say that Medicare considers reduction mammaplasty reconstructive for gynecomastia. Mastectomy 
with nipple preservation or reduction mammoplasty is considered reconstructive and medically reasonable and 
necessary: 
 
1. For males with unilateral or bilateral gynecomastia Grade III and IV as defined on the ASPS gynecomastia 
scale or abnormal breast development with redundancy. 
 
-Persists more than 3 to 4 months after pathological causes are ruled out. 
-Persists after 3 to 4 months of unsuccessful medical treatment for pathological gynecomastia 
 
2. Pain or tenderness directly related to the breast tissue which has a clinically significant impact upon 
activities of daily living. 
3. Clinical symptoms refractory to a trial of analgesics or anti-inflammatory agents. 
4. For significant clinical manifestations when the excessive breast weight adversely affects the supporting 
structures of the shoulders, neck, and trunk. 
 You can find this rule in the Local Coverage Determination (LCD) - Cosmetic and Reconstructive Surgery 
(L3509) - Effective July 11, 2021. 
 
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 Endoluminal Radiofrequency Ablation (ERFA) and laser ablation are covered only for the 
treatment of symptomatic varicosities of the lesser or greater saphenous veins and their tributaries which have 
failed 3 months of conservative therapy. 
 
You can find this information in the Local Coverage Determination (LCD) Treatment of Varicose Veins of the 
Lower Extremities L34010. 
 
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 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 pages 16 to 17 of the Plan's 
2021 Evidence of Coverage (EOC).