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. 
 
A standard walker (E0130, E0135, E0141, E0143) and related accessories are covered if all of the following 
criteria (1-3) are met: 
 
    1. The beneficiary has a mobility limitation that significantly impairs his/her ability to participate in one or 
more mobility-related activities of daily living (MRADL) in the home. 
 
    A mobility limitation is one that: 
 
        Prevents the beneficiary from accomplishing the MRADL entirely, or 
 
        Places the beneficiary at reasonably determined heightened risk of morbidity or mortality secondary to the 
attempts to perform the MRADL, or 
 
        Prevents the beneficiary from completing the MRADL within a reasonable time frame; and 
 
   2. The beneficiary is able to safely use the walker; and 
   3. The functional mobility deficit can be sufficiently resolved with use of a walker. 
 
If all of the criteria are not met, the walker will be denied as not reasonable and necessary. 
 
You can find this information in the Local Coverage Determination (LCD) Walkers L33791. 
 
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 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 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, Section 3.3.2.1. If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules say that immunizations are not covered unless they are directly related to the treatment of an injury or
direct exposure to a disease or condition. In the absence of injury or direct exposure, vaccination or inoculation
is not covered. However, pneumococcal, hepatitis B, influenza virus vaccines, and any COVID-19 vaccines
approved by the Food and Drug Administration (FDA) are exceptions to this rule. You can find this rule at 42
CFR Section 411.15(e) and Section 3713 of the Coronavirus Aid, Relief, and Economic Security Act (CARES
Act).

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 cosmetic surgery and related services, except as required for the prompt repair of accidental 
injury or to improve the functioning of a malformed body member, is not covered. You can find this rule at 42 
CFR Section 411.15(h). 
 
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 rules say that reconstruction of the affected and the contralateral unaffected breast following a medically 
necessary mastectomy is considered a relatively safe and effective non-cosmetic procedure. Accordingly, 
program payment may be made for breast reconstruction surgery following removal of a breast for any medical 
reason. Program payment may not be made for breast reconstruction for cosmetic reasons. (Cosmetic surgery is 
excluded from coverage under l862(a)(l0) of the Act.) 
 
National Coverage Determination (NCD): Breast Reconstruction Following Mastectomy (140.2). 
 
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 for crowns, one per tooth every five calendar years. You can find this information on pages 56 to 58 
of the Plans 2023 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 genetic testing for hereditary cardiovascular disease will be considered medically reasonable 
and necessary if: 
 
1. The patient has rigorous disease-appropriate phenotyping to establish clinical diagnosis or suspected 
diagnosis for which the test results would directly impact the management of the patients condition, prior to 
ordering the test 
AND 
2. The evidence for the gene-disease association is evaluated by the evidence-based, transparent, peer-reviewed 
process of the National Institutes of Health (NIH) sponsored Clinical Genome Resource (ClinGen) and is 
determined to demonstrate actionability in clinical decision making, meeting all bulleted metrics: 
 
a. Disease severity of sudden death, possible death or major morbidity, modest morbidity 
b. Substantial or moderate evidence of a >40% likelihood of disease 
c. Substantial or moderate evidence of a highly effective or moderately effective intervention 
d. The nature of intervention is either low risk/medically acceptable/low intensity intervention or moderately 
acceptable/risk/intensive interventions, 
AND 
 
3. Clinical validity and qualitative descriptors from Moderate, Strong & Definitive with contradictory evidence 
NOT being reported as disputed or refuted. 
 
You can find this rule in the Local Coverage Determination (LCD) - Genetic Testing for Cardiovascular 
Disease (L39084). 
 
The rules say that the following are considered not medically reasonable and necessary:  
1. A genetic test where either analytical validity, clinical validity, or clinical utility has not been established. 
2. Genetic testing in patients who do not demonstrate the disease-appropriate phenotype of the gene-disease 
association. 
3. Genetic testing of asymptomatic patients. 
4. Genetic testing solely for purposes of proband identification. 
5. Genetic testing with family history as the only indication. 
6. Gene tests for cardiovascular disease are considered germline testing, and therefore only permitted once per 
beneficiarys lifecycle. 
 
You can find this rule in the Local Coverage Determination (LCD) - Genetic Testing for Cardiovascular 
Disease (L39084). 
 
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 Centers for Medicare & Medicaid Services (CMS) covers percutaneous LAAC for non-
valvular atrial fibrillation (NVAF) through Coverage with Evidence Development (CED) with the following 
conditions: 
a. 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  2 (Congestive heart failure, Hypertension, Age > 75, Diabetes, Stroke/transient 
ischemia attack/thromboembolism) or CHA2DS2-VASc score  3 (Congestive heart failure, 
Hypertension, Age  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 rule in the Center for Medicare and Medicaid Services (CMS) Internet-Only Manual, 
Publication 100-03, Medicare National Coverage Determination (NCD) Manual, Section 20.34. 
 
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 Next Generation Sequencing (NGS) as a diagnostic laboratory test is reasonable and 
necessary and covered nationally, when performed in a Clinical Laboratory Improvement Amendments 
(CLIA)-certified laboratory, when ordered by a treating physician, and when all of the following requirements 
are met: 
   a. Patient has: 
i. either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer; and 
ii. not been previously tested with the same test using NGS for the same cancer genetic content, and 
iii. decided to seek further cancer treatment (e.g., therapeutic chemotherapy). 
   b. The diagnostic laboratory test using NGS must have:  
i. Food & Drug Administration (FDA) approval or clearance as a companion in vitro diagnostic; and 
ii. an FDA-approved or -cleared indication for use in that patients cancer; and 
iii. results provided to the treating physician for management of the patient using a report template to specify 
treatment options. 
 
You can find this in National Coverage Determination (NCD) Next Generation Sequencing (NGS) 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 say that current accepted diagnoses and indications for Mohs Micrographic Surgery:  
1. Basal cell carcinomas (BCC), squamous cell carcinomas (SCC), basalosquamous/basosquamous cell 
carcinomas in anatomic locations H and M. 
- Area H: Mask areas of face (central face, eyelids [including inner/outer canthi], eyebrows, 
nose, lips [cutaneous/mucosal/vermillion], chin, ear and periauricular skin /sulci, temple), 
genitalia (including perineal and perianal), hands, feet, nail units, ankles, and nipples/areola 
- Area M: Cheeks, forehead, scalp, neck, jawline, pretibial surface 
2. Basal cell carcinomas (BCC), squamous cell carcinomas (SCC), or basalosquamous/basosquamous cell 
carcinomas that are in anatomic locations H, M, and L (trunk and extremities) regardless of subtype, 
size, or depth arising in: 
- Prior radiated skin 
- Traumatic scar 
- Area of osteomyelitis 
- Area of chronic inflammation/ulceration 
- Patients with genetic syndromes 
3. Certain recurrent skin cancers: 
- Recurrent aggressive BCC, nodular BCC, superficial (except area L) BCC of any size, or 
unexpected positive margin on recent excision (healthy or immunocompromised patients with 
genetic syndromes) 
- Recurrent aggressive SCC, verrucous SCC, KA-type SCC (not central facial), in situ/Bowen 
SCC of any size or unexpected positive margin on recent excision (healthy or 
immunocompromised patients, or patients with genetic syndromes) 
4. Lentigo maligna, melanoma in situ, non-lentigo maligna - primary or locally recurrent in Areas H, M, L 
when clinical staging, work-up, and surgical treatment consistent with NCCN guidelines 
5. Less common skin cancers: 
- Adenocystic carcinoma 
- Adnexal carcinoma 
- Angiosarcoma 
- Apocrine/eccrine carcinoma - Atypical Fibroxanthoma 
- Dermatofibrosarcoma protuberans 
- Extramammary Pagets Disease 
- Leiomyosarcoma 
- Malignant fibrous histiocytoma/undifferentiated pleomorphic sarcoma 
- Merkel cell carcinoma 
- Microcystic adnexal carcinoma 
- Mucinous carcinoma 
- Sebaceous carcinoma 
You can find this information in Local Coverage Determination (LCD): Mohs Micrographic Surgery (MMS) 
(L33689). 
 
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 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, Section 3.3.2.1. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that 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 Next Generation Sequencing (NGS) as a diagnostic laboratory test is reasonable and 
necessary and covered nationally, when performed in a Clinical Laboratory Improvement Amendments 
(CLIA)-certified laboratory, when ordered by a treating physician, and when all of the following requirements 
are met: 
   a. Patient has: 
i. either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer; and 
ii. not been previously tested with the same test using NGS for the same cancer genetic content, and 
iii. decided to seek further cancer treatment (e.g., therapeutic chemotherapy). 
   b. The diagnostic laboratory test using NGS must have:  
i. Food & Drug Administration (FDA) approval or clearance as a companion in vitro diagnostic; and 
ii. an FDA-approved or -cleared indication for use in that patients cancer; and 
iii. results provided to the treating physician for management of the patient using a report template to 
specify treatment options. 
You can find this in National Coverage Determination (NCD) Next Generation Sequencing (NGS) 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 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 chemotherapy administration codes 96401-96549 apply to parenteral administration of non-
radionuclide anti-neoplastic drugs; and also to anti-neoplastic agents provided for treatment of noncancer 
diagnoses (e.g., cyclophosphamide for auto-immune conditions) or to substances such as certain monoclonal 
antibody agents, and other biologic response modifiers. The administration of codes, including but not limited 
to, J1602, should not be billed using a chemotherapy administration code. The IV administration of the drugs 
below should be billed with the appropriate IV injection/infusion CPT code listed under Therapeutic, 
Prophylactic, and Diagnostic Injections and Infusions in the CPT

 codebook. You can find this rule in the 
Local Coverage Article for the Billing and Coding for Complex Drug Administration Coding, A59073. 
 
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. You can find this information 
on page 82 of the Plans 2023 Evidence of Coverage (EOC).