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 state that Intravenous immune globulin (IVIG) is covered if all of the following criteria are met: 
1. It is an approved pooled plasma derivative for the treatment of primary immune deficiency disease; and 
2. The patient has a diagnosis of primary immune deficiency disease (See Diagnosis Codes that Support 
Medical Necessity section below); and 
3. The IVIG is administered in the home; and 
4. The treating practitioner has determined that administration of the IVIG in the patients home is 
medically appropriate. 
If all of the criteria are not met and the IVIG is not administered with an infusion pump, the IVIG will be 
denied as noncovered - no benefit category. 
You can find this rule in the Local Coverage Article for Intravenous Immune Globulin - Policy Article, 
A52509. 
 
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 & Medicaid Services, Medicare National Correct Coding Initiative Policy Manual for 
Medicare Services, Chapter I(A). 
 
The rules say that, when coding an adverse effect of a drug that has been correctly prescribed and properly 
administered, assign the appropriate code for the nature of the adverse effect followed by the appropriate code 
for the adverse effect of the drug (T36-T50). Examples of the nature of an adverse effect are tachycardia, 
delirium, gastrointestinal hemorrhaging, vomiting, hypokalemia, hepatitis, renal failure or respiratory failure. 
You can find this information in the Centers for Medicare & Medicaid Services, ICD-10-CM Guidelines, 
Section I.C.19.e.5.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 pays for care in a skilled nursing facility (SNF) when all of the following four 
factors are met: 
 
1. The patient requires skilled nursing or skilled rehabilitation services; 
2. The patient requires these services on a daily basis; 
3. As a practical matter, the daily skilled services can be provided only on an inpatient basis in a SNF; and 
4. The services are reasonable and necessary for the treatment of the patients illness or injury or the services 
must be needed to establish a safe and effective maintenance program or to prevent the patient's condition from 
getting worse.  
 
You can find these rules at 42 CFR Section 409.31 and in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 8, Section 30.   
 
The rules say that custodial care is not covered. Custodial care is personal care for a person who does not need 
ongoing care from trained medical or paramedical staff. Custodial care serves to help with the activities of 
daily living. This means the care includes help in walking, getting in and out of bed, bathing, dressing, feeding, 
and using the toilet. Fixing meals and taking charge of medicine that usually can be self-administered are also 
custodial care services. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 16, Section 110. 
 
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 sequela is the residual effect (condition produced) after the acute phase of an illness or 
injury has terminated. There is no time limit on when a sequela code can be used. The residual may be apparent 
early, such as in cerebral infarction, or it may occur months or years later, such as that due to a previous injury. 
Examples of sequela include: scar formation resulting from a burn, deviated septum due to a nasal fracture, and 
infertility due to tubal occlusion from old tuberculosis. Coding of sequela generally requires two codes 
sequenced in the following order: the condition or nature of the sequela is sequenced first. The sequela code is 
sequenced second. You can find this rule in the ICD-10-CM Official Guidelines for Coding and Reporting, 
Section I (10). 
 
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 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 payment may be made under the physician fee schedule for the professional component of 
physician laboratory or physician pathology services furnished to hospital inpatients or outpatients by hospital 
physicians or by independent laboratories, if they qualify as the re-assignee for the physician service. You can 
find this information in the Centers for Medicare and Medicaid Service, Internet-Only Manual, Publication 
100-04, Medicare Claims Processing Manual, Chapter 12, Section 60. A. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that the following are coverage criteria for monoclonal antibodies: 
 1) Monoclonal antibodies directed against amyloid that are approved by the FDA for the treatment of AD 
based upon evidence of efficacy from a change in a surrogate endpoint (e.g., amyloid reduction) considered as 
reasonably likely to predict clinical benefit may be covered in a randomized controlled trial conducted under an 
investigational new drug (IND) application. 
2) Monoclonal antibodies directed against amyloid that are approved by the FDA for the treatment of AD based 
upon evidence of efficacy from a direct measure of clinical benefit may be covered in CMS-approved 
prospective comparative studies. Study data for CMS-approved prospective comparative studies may be 
collected in a registry. 
3) For CMS-approved studies, the protocol, including the analysis plan, must include: 
1. A study population whose diversity of patients are representative of the national population with MCI due to 
AD or mild AD dementia. 
2. A neurocognitive evaluation and a description of the instruments used to assess cognition and function for 
the clinical diagnosis of MCI due to AD or mild AD dementia for study enrollment and outcomes assessment. 
3. A description of: 
1. The multidisciplinary dementia team and optimal medical management. 
2. Study sites with clinical expertise and infrastructure to provide treatments consistent with the safety 
monitoring outlined in the FDA-approved label. 
 
You can find this rule in the Centers for Medicare & Medicaid Services, Internet-Only Manual, Publication 
100-03, Medicare National Coverage Determinations (NCD) Manual, Section 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 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 Local Coverage Determination revised and published on October 4, 2018, to update the 
policy in response to inquiry and reconsideration requests; all literature reviewed and added to policy. Non-
coverage reaffirmed for CPT codes 0012M and 0013M for CxBladder. You can find this rule in the Local 
Coverage Determination 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 when certain component codes or mutually exclusive codes are appropriately furnished, such 
as later on the same day or on a different digit or limb, it is appropriate that these services be reported using a 
HCPCS code modifier. Such modifiers are modifiers E1 - E4, FA, F1 - F9, TA, T1 - T9, LT, RT, LC, LD, RC, 
-58, -78, -79, and -94. Application of these modifiers prevent erroneous denials of claims for several 
procedures performed on different anatomical sites, on different sides of the body, or at different sessions on 
the same date of service. The medical record must reflect that the modifier is being used appropriately to 
describe separate services.  You can find these rules in the Centers for Medicare & Medicaid Services (CMS), 
Internet-Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 30. 
 
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 PCDs coded as E0650, E0651, E0652 are used only in the treatment of lymphedema or CVI 
with venous stasis ulcers. Reimbursement for these items is based upon the criteria in the following sections. 
PCD coded as E0675 is used in the treatment of PAD. Claims for E0675 will be denied as not reasonable and 
necessary as outlined below. 
 
A PCD coded as E0650 or E0651 is covered for both primary and secondary lymphedema in beneficiaries with 
chronic and severe lymphedema when all of the following three requirements are met: 
 
   1. The beneficiary has a diagnosis of lymphedema as defined above, and 
   2. The beneficiary has persistence of chronic and severe lymphedema as identified by the documented 
presence of at least one of the following clinical findings: 
       - Marked hyperkeratosis with hyperplasia and hyperpigmentation, 
       - Papillomatosis cutis lymphostatica, 
       - Deformity of elephantiasis, 
       - Skin breakdown with persisting lymphorrhea, 
       - Detailed measurements over time confirming the persistence of the lymphedema with a history 
evidencing a likely etiology, and 
   3. In addition to this documented persistence, the lymphedema is then documented to be unresponsive to 
other clinical treatment over the course of a required four-week trial. (See below for trial guidelines.) 
 
A PCD coded as E0650 or E0651 used to treat lymphedema that does not meet all of the requirements above is 
not eligible for reimbursement. Claims will be denied as not reasonable and necessary. 
 
A PCD coded as E0650 or E0651 used to treat edema from causes other than lymphedema is not eligible for 
reimbursement. Claims will be denied as not reasonable and necessary. 
 
 PCD related accessories  are eligible for reimbursement only when the appropriate, related base PCDs (E0650, 
E0651, E0652, E0675) meets the applicable coverage criteria for that type of PCD. If the base PCD is not 
covered, related accessories are not eligible for reimbursement. Claims for related items will be denied as not 
reasonable and necessary. 
 
You can find this rule in the Local Coverage Determination (LCD) for Pneumatic Compression Devices 
(L33829). 
 
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 & Medicaid Services, Medicare National Correct Coding Initiative Policy Manual for 
Medicare Services, Chapter I(A). 
 
The rules state that the Centers for Medicare & Medicaid Services (CMS) issued replacement files for National 
Correct Coding Initiative (NCCI) Procedure to Procedure (PTP) edits for the October 1, 2023, files. Effective 
July 1, 2023, CMS implemented NCCI PTP edits between Column One codes 80305, 80306, and 80307 for 
presumptive test(s), and Column Two codes G0480  G0483, and G0659 for definitive test(s). CMS will 
withdraw these edits retroactive to July 1, 2023, in a replacement file for the 4th quarter of 2023. Claims with 
dates of service between July 1, 2023, and October 1, 2023, should be adjusted to allow payment as appropriate 
under existing payment and coverage policies. You can find this rule at Centers for Medicare & Medicaid 
Services National Correct Coding Initiative Edits bulletin published on the www.cms.gov website. 
 
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 Medicare will consider the use of short-latency somatosensory evoked potentials to be 
medically reasonable and necessary to assist in the diagnosis of certain neuropathologic states (as described 
below) to provide information for treatment decisions and for intraoperative electrophysiological monitoring 
during spinal surgeries in which there is risk of additional nerve or spinal cord injury. However, it is not 
anticipated that such monitoring will be medically necessary for the typical cervical or lumbar root 
decompression procedures. 
 
SEPs are used to evaluate the more proximal segments of nerves and the integrity of the central somatosensory 
pathways when abnormality of conduction through the brain and/or brainstem, spinal cord, and/or peripheral 
nerves is suspected. This utilization would include conditions such as multiple sclerosis, cervical spondylosis 
with myelopathy, coma, spinal cord trauma, myoclonus, Friedreichs ataxia, syringomyelia, spinal cord tumors, 
spinal stenosis and other conditions where there is spinal cord compression. 
 
Limitations: 
SEP studies are appropriate only when a detailed clinical history and neurologic examination and appropriate 
diagnostic tests such as imaging studies, electromyogram, and nerve conduction studies make a lesion (or 
lesions) of the central somatosensory pathways a likely and reasonable differential diagnostic possibility. 
 
You can find this rule at the Medicare Local Coverage Determination (LCD) L34624: Somatosensory Testing. 
 
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 & Medicaid Services, Medicare National Correct Coding Initiative Policy Manual for 
Medicare Services, Chapter I(A). 
 
The rules also say interpret the phrase new patient to mean a patient who has not received any professional 
services, i.e., evaluation and management (E/M) 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. For 
example, if a professional component of a previous procedure is billed in a 3-year time period, e.g., a lab 
interpretation is billed and no E/M service or other face-to-face service with the patient is performed, then this 
patient remains a new patient for the initial visit. An interpretation of a diagnostic test, reading an X-ray or 
electrocardiogram (EKG) etc., in the absence of an E/M service or other face-to-face service with the patient 
does not affect the designation of a new patient. You can find this rule in the Centers for Medicare & Medicaid 
Services, Internet-Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 
30.6.7. 
 
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 
coverage only for items and services listed in the Evidence of Coverage. Items and services not listed as a 
benefit are non-covered. You can find this information on pages 59 & 60 of the 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 a health plan must disclose to its enrollees in clear, accurate terms all cost sharing information 
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and 
(b). 
 
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say 
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to 
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2.  
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that enrollees must pay 20% coinsurance for Medicare Part B prescription drugs. You can find 
this information on page 4-28 of the Plan's 2022 Evidence of Coverage (EOC).  
 
The Plan contract also says that enrollees must pay a $20 copayment per specialist visit. You can find this 
information on page 4-42 of the Plans 2022 EOC.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that Medicare has a non-coverage policy for genetic testing for thrombophilia testing for the 
Factor V Leiden (FVL) variant in F5 gene, the 20210G>(G20210A) variant in the F2 gene, and the MTHFR 
gene which encodes the 5, 10 methylenetetrahydrofolate reductase enzyme. Genetic testing for these genes for 
all risk factors, signs, symptoms, diseases, or conditions, including cardiovascular risk assessment, are non-
covered except for pregnant patients. This rule is found in Local Coverage Determination (LCD): MolDX: 
Genetic Testing for Hypercoagulability/Thrombophilia (Factor V Leiden, Factor II Prothrombin, and MTHFR) 
(L36400). 
 
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.