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

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that providers/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 to interpret the phrase "new patient" to mean a patient who has not received any professional 
services, i.e., evaluation and management service or other face-to-face service (e.g. surgical procedure) from 
the physician or physician group practice (same physician specialty) within the previous 3 years. You can find 
this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, 
Medicare Claims Processing Manual, Chapter 12, Section 30.6.7. 
 
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 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 the 
surgical placement of implant body; endosteal (D6010) (2 of D6010, D6013) every calendar year, 1 per tooth 
every 5 calendar years when the teeth that are holding the bridge have a good long-term outcome. You can find 
this information in Chapter 4 on pages 58 to 59 of the Plans 2023 Evidence of Coverage (EOC) and in the 
Dental Plan Clinical Criteria maintained by the Plan's dental benefit administrator.
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 is the secondary payer to certain primary plans. When Medicare is the secondary 
payer, the provider or enrollee must first submit the claim to the primary payer. If the primary payer does not 
pay in full for the services, Medicare secondary benefits may be paid. The enrollee must file a claim with the 
primary payer or cooperate fully with the provider so that the provider can file the necessary claim. You can 
find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-05, 
Medicare Secondary Payer Manual, Chapter 1, Section 20 and Chapter 3, Section 10.8.  
 
The rules say that plans must identify payers that are primary to Medicare, identify the amounts payable by the 
primary payer, and coordinate benefits to Medicare enrollees with the benefits of the primary payer. You can 
find this rule at 42 CFR Section 422.108. 
 
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 insurance that pays first is called the primary payer and pays up to the limits of 
coverage. The one that pays second, called the secondary payer, only pays if there are costs left uncovered by 
the primary coverage. The secondary payer may not pay all of the uncovered costs. You can find this 
information on page 23 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 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. 
 
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 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 state that the provider submitting a claim for diagnostic testing or lab services must maintain 
additional diagnostic and other medical information from the ordering physician or nonphysician practitioner to 
document that the services it bills are reasonable and necessary. Providers must request and provide material 
relevant to the medical necessity of the specific test(s), taking into consideration current rules and regulations 
on patient confidentiality. You can find this rule at 42 CFR 410.32 (d)(3)(iii). 
 
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 footwear billed with code L3260 is noncovered.  You can find this rule at Centers for 
Medicare and Medicaid Services, Local Coverage Determination Policy Article A52481. 
 
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 an Implantable (or Insertable Loop) Recorder (ILR) is another type of pre-symptom Memory 
Loop Recorder (MLR) that is implanted subcutaneously in a patients upper left chest and may remain 
implanted for many months. An ILR is used when syncope is thought to be cardiac-related but is too infrequent 
to be detected by either a Holter monitor or a traditional pre-symptom MLR. You can find this information in 
the Centers for Medicare and Medicaid Services (CMS), Internet-Only Manual, Publication 100-03, Medicare 
National Coverage Determinations (NCD) Manual, Section 20.15. 
 
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 30-day period of care is the unit of payment for home health prospective payment 
system (PPS). The period of care payment is specific to one individual homebound beneficiary. The beneficiary 
can be covered for an unlimited number of non-overlapping periods of care. For periods of care beginning on 
or after January 1, 2020, the duration of a period is 30 days. Period of care may be shorter than 30 days. You 
can find this rule in Medicare Claims Processing Manual Chapter 10, Sections 10.1.4 and 10.1.5. 
 
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 Plan 
contract says that they have a link will take you to a list of Part B Drugs that may be subject to Step Therapy. 
You can find this information in Chapter 4 on page 62 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 say that a spinal orthosis (L0450 - L0651) is covered when it is ordered for one of the following 
indications: 
 
-To reduce pain by restricting mobility of the trunk; or 
 
-To facilitate healing following an injury to the spine or related soft tissues; or 
 
-To facilitate healing following a surgical procedure on the spine or related soft tissue; or 
 
-To otherwise support weak spinal muscles and/or a deformed spine. 
 
If a spinal orthosis is provided and the coverage criteria are not met, the item will be denied as not medically 
necessary. You can find this rule in Local Coverage Determination (LCD): Spinal Orthoses: TLSO and LSO 
(L33790). 
 
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 term DME is defined as equipment which: 
 
Can withstand repeated use; i.e., could normally be rented and used by successive patients; 
Is primarily and customarily used to serve a medical purpose; 
Generally is not useful to a person in the absence of illness or injury; and, 
Is appropriate for use in a patients home. 
 
You can find this information in the National Coverage Determination (NCD) Durable Medical Equipment 
Reference List 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 if medically necessary and reasonable, Medicare will cover one Fluorodeoxyglucose (FDG) 
Positron Emission Tomography (PET) scan to determine the initial level of cancer treatment needed for an 
enrollee. After the completion of the initial anti-cancer therapy, additional FDG PET scans may be covered at 
the discretion of Medicare. You can find this rule in the Centers for Medicare and Medicaid Services, Internet 
Only Manual, Publication 100-03, National Coverage Determinations Manual, Section 220.6.17. 
 
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/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 the submitted medical record must support the use of the selected ICD-10-CM code(s). You 
can find this information in the Local Coverage Article A57125: Billing and Coding: Non-Invasive Evaluation 
of Extremity Veins. 
 
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 Next Generation Sequencing (NGS) testing is only covered for patients with somatic 
(Acquired) Cancer when the following criteria are met: 
 
a. The patient has either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer; and 
not been previously tested with the same test using NGS for the same cancer genetic content, and 
decided to seek further cancer treatment (e.g., therapeutic chemotherapy); and 
b. The diagnostic laboratory test using NGS must have Food & Drug Administration (FDA) approval. 
 
You can find this rule at Centers for Medicare and Medicaid Services, Internet-Only Publication 100-03, 
Medicare National Coverage Determinations Manual 90.2. 
 
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.
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 capped rental items, providers should bill with the RR modifier (to indicate that the item 
is a capped rental) in addition to a modifier to indicate the month of rental.  These modifiers are KH (to 
indicate the first month of rental), KI (to indicate the second and third rental months), and KJ (fourth to the 
13th month).  You can find this rule at Centers for Medicare and Medicaid Services, Durable Medical 
Equipment Region D (Noridian Healthcare Solutions) article entitled "Capped Rental Items." 
 
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 effective for services performed on or after December 7, 2016, CMS will cover through a 
prospective, longitudinal study PILD procedures using an FDA-approved/cleared device that completed a 
CMS-approved randomized control trial (RCT) that met the criteria listed in section I above. 
 
The CMS-approved prospective, longitudinal study must answer at least one of the following questions: 
 
    Does PILD provide a clinically meaningful improvement of function (e.g., reduced acute and post-acute 
hospitalizations, nursing home care or inpatient rehabilitation services) and/or quality of life in Medicare 
beneficiaries with LSS compared to other treatments? 
    Does PILD provide a clinically meaningful reduction in pain (e.g., as measured by class, dose, duration of 
prescription pain medication use) in Medicare beneficiaries with LSS compared toother treatments? 
    Does PILD affect the overall clinical management of LSS and decision making, including use of other 
medical treatments or services (e.g., repeat PILD procedures, other interventions and surgical treatments), 
compared to other treatments? 
 
The prospective, longitudinal study must also meet the following criteria: 
 
    The protocol must specify a statistical analysis and a minimum length of patient follow-up time that 
evaluates the effect of beneficiary characteristics on patient health outcomes as well as the duration of the 
benefit. 
    The eligibility requirements, both inclusion and exclusion criteria that were specified in the CMS-approved 
RCT protocol, must be maintained in the new prospective, longitudinal study. 
    All study sites and study results must be listed in the ClinicalTrials.gov database 
 
You can find this information in the National Coverage Determination (NCD) Percutaneous Image-Guided 
Lumbar Decompression for Lumbar Spinal Stenosis 150.13. 
 
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/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 certain conditions have both an underlying etiology and multiple body system manifestations 
due to the underlying etiology. For such conditions, the ICD-10-CM has a coding convention that requires the 
underlying condition be sequenced first, if applicable, followed by the manifestation. Wherever such a 
combination exists, there is a use additional code note at the etiology code, and a code first note at the 
manifestation code. These instructional notes indicate the proper sequencing order of the codes, etiology 
followed by manifestation. You can find this information in the ICD-10-CM Official Guidelines for Coding 
and Reporting FY 2022. 
 
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 covers Percutaneous Left Atrial Appendage Closure (LAAC) for non-valvular 
atrial fibrillation (NVAF) through Coverage with Evidence Development (CED) with the following conditions: 
 
    LAAC devices are covered when the device has received Food and Drug Administration (FDA) Premarket 
Approval (PMA) for that devices FDA-approved indication and meet all of the conditions specified below: 
 
The patient must have: 
 
    A CHADS2 score equals 2 (Congestive heart failure, Hypertension, Age greater than 75, Diabetes, 
Stroke/transient ischemia attack/thromboembolism) or CHA2DS2-VASc score equals 3 (Congestive heart 
failure, Hypertension, Age equals 65, Diabetes, Stroke/transient ischemia attack/thromboembolism, Vascular 
disease, Sex category) 
    A formal shared decision making interaction with an independent non-interventional physician using an 
evidence-based decision tool on oral anticoagulation in patients with NVAF prior to LAAC. Additionally, the 
shared decision making interaction must be documented in the medical record. 
    A suitability for short-term warfarin but deemed unable to take long-term oral anticoagulation following the 
conclusion of shared decision making, as LAAC is only covered as a second line therapy to oral anticoagulants. 
The patient (preoperatively and postoperatively) is under the care of a cohesive, multidisciplinary team (MDT) 
of medical professionals. The procedure must be furnished in a hospital with an established structural heart 
disease (SHD) and/or electrophysiology (EP) program. 
 
You can find this information in the Centers for Medicare and Medicaid Services (CMS), Internet-Only 
Manual, Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Section 20.34. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.