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 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 reconstructive surgery is performed to restore and improve function and correct any 
deformities or abnormal structures of the body that have been caused by congenital defects, developmental 
abnormalities, trauma, infection, tumors or disease. 
 
Macromastia (breast hypertrophy) is an increase in the volume and weight of breast tissue relative to the 
general body habitus. Breast hypertrophy may adversely affect other body systems (e.g., musculoskeletal, 
respiratory, integumentary). At times, unilateral hypertrophy may result in symptoms following contralateral 
mastectomy. Considerable attention has been given to the amount of breast tissue removed in differentiating 
between cosmetic and medically reasonable and necessary reduction mammoplasty. Arbitrary minimum weight 
breast tissue removed criteria do not consistently reflect the consequences of mammary hypertrophy in 
individuals with a unique body habitus. There are wide variations in the range of height, weight and associated 
breast size that cause symptoms. The amount of tissue that must be removed to relieve symptoms will vary and 
depend upon these variations. You can find this rule in the Local Coverage Determination for Cosmetic and 
Reconstructive Surgery, L35090 (eff 07/11/21). 
 
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 pages 71 and 122 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 state that coverage of other pumps is addressed under indications IV, V (E), and V (H). 
 
Administration of continuous subcutaneous insulin for the treatment of diabetes mellitus (Refer to the ICD-10 
code list in the LCD-related Policy Article for applicable diagnoses.) if criterion A or B is met and if criterion 
C or D is met: 
 
    C-peptide testing requirement  must meet criterion 1 or 2 and criterion 3: 
        C-peptide level is less than or equal to 110 percent of the lower limit of normal of the laboratory's 
measurement method. 
        For beneficiaries with renal insufficiency and a creatinine clearance (actual or calculated from age, weight, 
and serum creatinine) less than or equal to 50 ml/minute, a fasting C-peptide level is less than or equal to 200 
per cent of the lower limit of normal of the laboratorys measurement method. 
        A fasting blood sugar obtained at the same time as the C-peptide level is less than or equal to 225 mg/dl. 
    Beta cell autoantibody test is positive. 
    The beneficiary has completed a comprehensive diabetes education program, has been on a program of 
multiple daily injections of insulin (i.e., at least 3 injections per day) with frequent self-adjustments of insulin 
dose for at least 6 months prior to initiation of the insulin pump, and has documented frequency of glucose self-
testing an average of at least 4 times per day during the 2 months prior to initiation of the insulin pump, and 
meets one or more of the following criteria (1 - 5) while on the multiple injection regimen: 
        Glycosylated hemoglobin level (HbA1C) greater than 7 percent 
        History of recurring hypoglycemia 
        Wide fluctuations in blood glucose before mealtime 
        Dawn phenomenon with fasting blood sugars frequently exceeding 200 mg/dL 
        History of severe glycemic excursions 
    The beneficiary has been on an external insulin infusion pump prior to enrollment in Medicare and has 
documented frequency of glucose self-testing an average of at least 4 times per day during the month prior to 
Medicare enrollment. 
 
If criterion A or B is not met, the pump and related accessories, supplies, and insulin will be denied as not 
reasonable and necessary. If criterion C or D is not met, the pump and related accessories, supplies, and insulin 
will be denied as not reasonable and necessary. 
 
 Subcutaneous insulin is administered using ambulatory infusion pump E0784. Claims for usage of infusion 
pumps other than E0784 will be denied as not reasonable and necessary. 
 
You can find this information in the Local Coverage Determination (LCD) External Infusion Pumps L33794. 
 
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 Gradient Compression Wrap (A6545) 
 
A gradient compression wrap is only covered when it is used as a primary or secondary dressing over wounds 
that meet the statutory requirements for a qualifying wound (surgically created or modified, or debrided). 
 
Claims for gradient compression wraps used without a qualifying wound or when used for other non-qualifying 
conditions will be denied as statutorily non-covered, no benefit. Refer to the related Policy Article NON-
MEDICAL NECESSITY COVERAGE AND PAYMENT RULES for information about the statutory benefit 
requirements. 
 
Utilization of a gradient compression wrap (A6545) is limited to one per 6 months per leg. Quantities 
exceeding this amount will be denied as not reasonable and necessary. Refer to the related Surgical Dressings 
Policy Article NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES section for information 
concerning non-coverage once the ulcer has healed. 
 
GRADIENT COMPRESSION STOCKINGS/WRAPS (A6531, A6532, A6545) 
 
A gradient compression stocking described by codes A6531 or A6532 or a non-elastic gradient compression 
wrap described by code A6545 is only covered when it is used in the treatment of an open venous stasis ulcer 
that meets the qualifying wound requirements described above. 
 
Codes A6531, A6532, and A6545 are non-covered for the following conditions: 
 
    Venous insufficiency without stasis ulcers; 
    Prevention of stasis ulcers; 
    Prevention of the reoccurrence of stasis ulcers that have healed; 
    Treatment of lymphedema in the absence of ulcers. 
 
You can find this information in Medicare's Local Coverage Determination (LCD): Surgical Dressings 
(L33831) and Local Coverage Article Surgical Dressings - Policy Article (A54563). 
 
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 Computed Tomographic Angiography (CTA). CTA is a general phrase used to describe a 
non-invasive method, using intravenous contrast, to visualize the coronary arteries (or other vessels) using 
high-resolution, high- speed CT. 
 
After examining the medical evidence, the Centers for Medicare and Medicaid Services has determined that no 
national coverage determination is appropriate at this time (March 12, 2008). Section 1862(a)(1)(A) of the 
Social Security Act decisions should be made by local MACs through a local coverage determination process 
or case-by-case adjudication. See Heckler v. Ringer, 466 U.S. 602, 617 (1984) (Recognizing that the Secretary 
has discretion to either establish a generally applicable rule or to allow individual adjudication.). See also, 68 
Fed. Reg. 63692, 63693 (November 7, 2003). You can find this rule at Centers for Medicare and Medicaid 
Services, National Coverage Determination, NCD 220.1, Computed Tomography. 
 
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). 
 
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 medically accepted off-label uses for Food and Drug Administration 
(FDA) approved drugs used in an anti-cancer chemotherapeutic regimen. Medicare maintains a list of 
compendia which define if a use is medically accepted.  
  
  The off-label use must be supported in one or more of these compendia or in published, peer-reviewed medical 
literature. An off-label use must be supported in one or more of the compendia and the use must not be listed as 
unsupported, not indicated, not recommended, or equivalent terms, in any of the compendia. An off-label use 
may also be determined by the carrier in the state to be reasonable and necessary. You can find these rules and 
the list of the Medicare-recognized compendia in the Centers for Medicare and Medicaid Services, Internet 
Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 50.4.5. 
 
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. The health 
plan contract says that covered drugs include Drugs that usually arent self-administered by the patient and are 
injected or infused while you are getting physician, hospital outpatient, or ambulatory surgical center services. 
You can find this information in Chapter 4 on page 68 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 facet joint interventions are considered medically reasonable and necessary for the diagnosis 
and treatment of chronic pain in patients who meet ALL of the following criteria: 
 
1. Moderate to severe chronic neck or low back pain, predominantly axial, that causes functional deficit 
measured on pain or disability scale, and 
2. Pain that has been present for a minimum of 3 months with documented failure to respond to noninvasive 
conservative care management (as tolerated), and 
3. Absence of untreated radiculopathy or neurogenic claudication (except for radiculopathy caused by facet 
joint synovial cyst) 
4. There is no non-facet pathology per clinical assessment or radiology studies that could explain the source of 
the patients pain, including but not limited to fracture, tumor, infection, or significant deformity. 
 
You can find this rule in Local Coverage Determination (LCD): Facet Joint Interventions for Pain Management 
(L35936) - Effective April 25, 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 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 health 
plan contract says that they have a link that 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 100 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 procedure codes with a status indicator of X are statutorily excluded. These codes represent 
an item or service that is not in the statutory definition of physician services for fee schedule payment 
purposes. You can find this rule in the Centers for Medicare and Medicaid Services (CMS), Internet-Only 
Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 23, Section 30.2.2. 
 
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 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 a physician/practitioner/supplier furnishing services to a patient who is a registered inpatient, 
shall, at a minimum, report the inpatient hospital Place of Service (POS) code 21 irrespective of the setting 
where the patient actually receives the face-to-face encounter. You can find this information at Medicare 
Claims Processing Manual Chapter 26, Section 10.5. 
 
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 state that Criteria for Testing 
1. Individual with breast, ovarian, pancreatic, or prostate cancer from a family with a known deleterious 
BRCA1 or BRCA2 gene mutation 
2. Individual with a personal history of ovarian cancer 
3. Individual with a breast cancer diagnosis meeting any of the following criteria:  
A. Diagnosed 45 y 
B. Triple negative breast cancer (estrogen receptor (ER) negative, progesterone receptor (PR) 
negative, and human epidermal growth factor receptor 2 (HER2) negative) breast cancer 
diagnosed  60 y 
C. Diagnosed at 46-50 y with:  
i. An additional breast cancer primary 
ii. 1 first, second, or third degree relative with breast cancer at any age, or 
iii. 1 first, second, or third degree relative with prostate cancer (Gleason score 7), or 
iv. An unknown or limited family history 
D. Breast cancer diagnosed at any age, and  
i. 1 first, second, or third degree relative with breast cancer 50 y, or 
ii. 1 first, second, or third degree relative with ovarian cancer at any age, or 
iii. 1 first, second, or third degree relative with metastatic prostate cancer or pancreatic 
cancer at any age, or 
iv. 2 additional diagnoses of breast cancer at any age in patient and/or in close blood 
relative, or 
v. A first, second, or third degree male relative with breast cancer 
vi. For an individual of ethnicity associated with higher mutation frequency (e.g. Ashkenazi 
Jewish
4
) no additional family history may be required. 
E. Male breast cancer 
4. Personal history of prostate cancer (Gleason score7) at any age with: 
A. 1 first, second, or third degree relative with ovarian cancer at any age, or 
B. 1 first, second, or third degree relative with breast cancer 50 y, or 
C. 1 first, second, or third degree relative pancreatic cancer at any age, or 
D. 1 first, second, or third degree relative
 
with metastatic prostate cancer at any age, or 
E. 2 first, second, or third degree relatives with breast cancer and/or pancreatic cancer and/or 
prostate cancer (any grad) at any age, or 
F. Ashkenazi Jewish ancestry 5. Personal history of pancreatic cancer at any age 
6. Personal history of metastatic prostate cancer (radiographic evidence of or biopsy-proven disease) 
7. BRCA1/2 pathogenic mutation detected by tumor profiling on any tumor type in the absence of 
germline mutation analysis 
 
You can find more information in Local Coverage Determination (LCD): MolDX: BRCA1 and BRCA2 
Genetic Testing (L36163). 
 
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 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. 
For a beneficiary who is currently being treated with insulin administrations, more than 300 test strips and 
more than 300 lancets every 3 months are covered if criteria (a)  (c) below are met. 
a. Basic coverage criteria (1)-(2) listed above for all home glucose monitors and related accessories and 
supplies are met; and, 
b. Within the six (6) months prior to ordering quantities of strips and lancets that exceed the utilization 
guidelines, the treating practitioner has had an in-person visit with the beneficiary to evaluate their 
diabetes control and their need for the specific quantity of supplies that exceeds the usual utilization 
amounts described above; and, 
c. Every six (6) months, for continued dispensing of quantities of testing supplies that exceed the usual 
utilization amounts, the treating practitioner must verify adherence to the high utilization testing 
regimen. 
If neither basic coverage criterion (1) or (2) is met, all testing supplies will be denied as not reasonable and 
necessary. If quantities of test strips or lancets that exceed the utilization guidelines are provided and criteria 
(a)  (c) are not met, the amount in excess will be denied as not reasonable and necessary. 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.