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 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 CT scans are covered if there is literature to support its use for the patients condition and the 
scan is reasonable and necessary for the patient. You can find this rule in the Centers for Medicare and 
Medicaid Services, Internet Only Manual, Publication 100-03, Medicare National Coverage Determinations 
Manual, Section 220.1(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 a Medicare plan may restrict members to a network of providers as long as medically necessary covered care is accessible and available through this network. The rules say that the Plan must arrange for specialty care outside of the Plan provider network when network providers are unavailable or inadequate to meet a member's medical needs. You can find this rule at 42 CFR Section 422.112(a)(3).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that, with limited exceptions, members of the Plan must use network providers to get medical care and services. The only exceptions are emergencies, urgently needed care when the network is not available (generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan authorizes the use of out-of-network providers. You can find this information on page 11 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. 
 
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 Plan covers an annual routine preventive physical exam. Non-Medicare covered 
routine physical exams are covered once every calendar year. You can find this information on page 63 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 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 genes not identified as having actionable use are not considered reasonable and necessary. 
The algorithms employed in combinatorial testing are also not currently considered reasonable and necessary 
components of multi-gene testing. You can find this rule in Local Coverage Determination (LCD) MolDX: 
Pharmacogenomics Testing L38294. 
 
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 adhesive catheter anchoring devices (A4333) and catheter leg straps (A4334) for indwelling 
urethral catheters are covered. More than 3 per week of A4333 or 1 per month of A4334 will be denied as not 
reasonable and necessary. A catheter/tube anchoring device (A5200) is covered and separately payable when it 
is used to anchor a covered suprapubic tube or nephrostomy tube. If code A5200 is used to anchor an 
indwelling urethral catheter, the claim will be denied as not reasonable and necessary. 
 
URINARY DRAINAGE COLLECTION SYSTEM (A4314, A4315, A4316, A4354, A4357, A4358, A5102, 
and A5112) 
 
Payment will be made for routine changes of the urinary drainage collection system as noted below. Additional 
charges will be allowed for reasonable and necessary non-routine changes when the documentation 
substantiates the medical necessity, (e.g., obstruction, sludging, clotting of blood, or chronic, recurrent urinary 
tract infection). 
 
Usual Maximum Quantity of Supplies: 
A4358     2 per month 
 
You can find these rules in the Local Coverage Determination (LCD) Urological Supplies L33803. 
 
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 if a laboratory procedure produces multiple reportable test results, only a single HCPCS/CPT 
code shall be reported for the procedure. If there is no Healthcare Common Procedure Coding System 
(HCPCS)/Current Procedural Terminology (CPT) code that describes the procedure, the laboratory shall report 
a miscellaneous or unlisted procedure code with a single unit of service. You can find this rule in Centers for 
Medicare & Medicaid Services (CMS) National Correct Coding Initiative Coding Policy Manual for Medicare 
Services (page X-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 continuous passive motion devices (CPM devices) are covered only for patients who have 
received a total knee replacement. There is insufficient evidence to justify coverage for other applications. You 
can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-
03, Medicare Coverage Determinations Manual, Section 280.1.  
 
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 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); AND 
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 the Local Coverage Determination (LCD): Facet Joint Interventions for Pain 
Management (L34892). 
 
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 molecular diagnostic laboratory tests must undergo an application and technical assessment 
process through the Molecular Diagnostics (MolDX) contractor. MolDX will review all new test/assay clinical 
information to determine if a test meets Medicares reasonable and necessary requirement. Labs must submit a 
comprehensive dossier on each new test/assay prior to claim submission. MolDX will only cover and 
reimburse tests that demonstrate analytical and clinical validity, and clinical utility at a level that meets the 
Medicare reasonable and necessary requirement. This rule requires that all tests that are approved by this 
process be assigned a unique test identifier from the DEXTM Diagnostics Exchange. Only approved tests will be 
reimbursed consistent with the effective date of the coverage determination. This unique identifier must be 
reported on the claim. You can find this rule in the Local Coverage Determination (LCD): MolDX: Molecular 
Diagnostic Tests (MDT) L35025 and the related Local Coverage Article: Billing and Coding: MolDX: 
Molecular Diagnostic Tests (MDT) A56853. 
 
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 Physician Fee Schedule Status Indicator B means that payment for covered services is 
always bundled into payment for other services not specified. There will be no payment amounts for these 
codes and no separate payment is ever made. When these services are covered, payment for them is subsumed 
by the payment for the services to which they are incident. You can find this information in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing 
Manual, Chapter 23, 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 use of an International Classification of Diseases (ICD)-10-CM code listed below does not assure coverage 
of a service. The service must be reasonable and necessary in the specific case and must meet the criteria 
specified in the attached determination. 
 
MRA of the Head & Neck can be covered for these diagnoses: 
 
R29.818- Use for patients presenting with signs and symptoms strongly suggesting an intracerebral aneurysm, 
without the MRA finding of an aneurysm. 
 
You can find this information in Medicare's Local Coverage Article (LCA): Billing and Coding: Magnetic 
Resonance Angiography (MRA) (A56747). 
 
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 Physician Fee Schedule Status Indicator B means that payment for covered services is 
always bundled into payment for other services not specified. There will be no payment amounts for these 
codes and no separate payment is ever made. When these services are covered, payment for them is subsumed 
by the payment for the services to which they are incident. The rules say that the Physician Fee Schedule Status 
Indicator T means there are relative value units (RVUs) and payment amounts for these services, but they are 
only paid if there are no other services payable under the physician fee schedule billed on the same date by the 
same provider. If any other services payable under the physician fee schedule are billed on the same date by the 
same provider, these services are bundled into the physician services for which payment is made. You can find 
this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, 
Medicare Claims Processing Manual, Chapter 23, 30.2.2. 
 
The rules say that Unique Test Identifier Requirement: Because the available language in the current HIPAA 
compliant code sets used to describe the pathology and laboratory categories and the tests included in those 
categories are not specific to the actual test results provided, all MDT services must include an identifier as 
additional claim documentation. Test providers must receive an identifier specific to the applicable test and 
submit the test assigned identifier with the claim for reimbursement. The assigned identifier will provide a 
crosswalk between the test's associated detail information on file and the submitted claim detail line(s) required 
to adjudicate each test's claim. You can find this information in the Local Coverage Determination (LCD): 
MolDX: Molecular Diagnostic Tests (MDT) (L35025) and Local Coverage Article (LCA): Billing and Coding: 
MolDX: Molecular Diagnostic Tests (MDT) (A56853).  
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 equipment which the enrollee owns or is a capped rental item may be replaced in cases of 
loss or irreparable damage. Irreparable damage refers to a specific accident or to a natural disaster (e.g., fire, 
  
  flood). A physicians order and/or new Certificate of Medical Necessity (CMN), when required, is needed to 
reaffirm the medical necessity of the item. 
Irreparable wear refers to deterioration sustained from day-to-day usage over time and a specific event cannot 
be identified. Replacement of equipment due to irreparable wear takes into consideration the reasonable useful 
lifetime of the equipment. If the item of equipment has been in continuous use by the enrollee on either a rental 
or purchase basis for the equipments useful lifetime, the enrollee may elect to obtain a new piece of 
equipment. Replacement may be reimbursed when a new physician order and/or new CMN, when required, is 
needed to reaffirm the medical necessity of the item. 
The reasonable useful lifetime of durable medical equipment is determined through program instructions. In the 
absence of program instructions, A/B MACS (B) may determine the reasonable useful lifetime (RUL) of 
equipment, but in no case can it be less than 5 years. Computation of the useful lifetime is based on when the 
equipment is delivered to the enrollee, not the age of the equipment. Replacement due to wear is not covered 
during the reasonable useful lifetime of the equipment. During the reasonable useful lifetime, Medicare does 
cover repair up to the cost of replacement (but not actual replacement) for medically necessary equipment 
owned by the enrollee. These rules can be found in the Medicare Benefit Policy Manual Chapter 15, Section 
110.2 for Repairs, Maintenance, Replacement, and Delivery. 
 
The rules say that ankle-foot orthoses (AFO) described by codes L1970 are covered for ambulatory 
beneficiaries with weakness or deformity of the foot and ankle, who: 
 
Require stabilization for medical reasons, and, 
 
Have the potential to benefit functionally. 
 
For custom fabricated orthoses (L1970), there must be detailed documentation in the treating practitioner's 
records to support the medical necessity of custom fabricated rather than a prefabricated orthosis as described 
in the Coverage Indications, Limitations, and/or Medical Necessity section of the related LCD. This 
information will be corroborated by the functional evaluation in the orthotist or prosthetists records. This 
information must be available upon request. 
 
You can find this information in Medicare's Local Coverage Determination (LCD): Ankle-Foot/Knee-Ankle-
Foot Orthosis (L33686). 
 
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 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 pages 91 to 102 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 state that the use of a telecommunications system may substitute for an in-person encounter for 
professional consultations, office visits, office psychiatry services, and a limited number of other physician fee 
schedule (PFS) services. The various services and corresponding current procedure terminology (CPT) or 
Healthcare Common Procedure Coding System (HCPCS) codes are listed on the CMS website at 
www.cms.gov/Medicare/Medicare-General-Information/Telehealth/. You can find this rule in the Centers for 
Medicare and Medicaid Services, Internet-Only Manual, Publication 100-104, Chapter 12, Section 190.3. 
 
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 state that the right (RT) and/or left (LT) modifiers must be used with all  eye prosthesis codes. When 
the same code for bilateral items (left and right) is billed on the same date of service, providers must bill each 
item on two separate claim lines using the RT and LT modifiers and 1 unit of service (UOS) on each claim line. 
Providers should not use the RTLT modifier on the same claim line and billed with 2 UOS. Claims billed 
without the RT and/or LT modifiers, or with RTLT on the same claim line and 2 UOS, will be rejected as 
incorrect. You can find this rule at Centers for Medicare and Medicaid Services Local Coverage Article 
A52462 entitled Eye Prostheses. 
 
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 Place of Service (POS) code is generally used to reflect the actual setting where the 
beneficiary receives the face to-face service. However, there are two exceptions to this general rule  these are 
for a service rendered to a patient who is a registered inpatient or an outpatient of a hospital. In these cases, the 
correct POS code -- regardless of where the face-to-face service occurs -- is that of the appropriate inpatient 
POS code (at a minimum POS code 21) or that of the appropriate outpatient hospital POS code (at a minimum 
POS code 19 or 22, for outpatient services performed off campus or on campus). You can find this information 
in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare 
Claims Processing Manual, Chapter 26, Section 10.6. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.