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  
1. WCE is indicated for the diagnosis of occult gastrointestinal (GI) bleeding, the site of which has not 
previously been identified by any of the following: upper gastrointestinal endoscopy, colonoscopy, push 
enteroscopy, nuclear imaging or radiological procedures. 
2. WCE is limited to those patients who have undergone upper GI endoscopy and colonoscopy and these 
tests have failed to reveal a source of bleeding. Medicare would not expect to see a WCE provided if 
upper and lower endoscopy has not previously been performed. Documentation in the medical record 
must indicate that the beneficiary has suspected GI blood loss with or without anemia. Appropriate 
differential diagnoses for the evaluation of such bleeding include: 
-Angiodysplasia 
-Neoplasm 
-Iron deficiency anemia, which is unexplained after upper and lower endoscopy 
-Zollinger-Ellison syndrome 
-Tuberculosis 
-Vasculitis 
-Radiation enteritis 
-Meckels diverticulum 
-Jejunal diverticula -Chronic mesenteric ischemia 
3. Other indications include the management of celiac disease and of Crohns disease (that is, either 
Crohns disease is suspected, but not diagnosed, or colonic involvement of Crohns disease is known, 
but it is necessary to determine whether there is also involvement of the small bowel). In addition, WCE 
is indicated where an indeterminate type of colitis exists, but where a more specific diagnosis is being 
sought via small bowel evaluation. 
4. Esophageal capsule endoscopy may be used in the evaluation of esophageal varices in patients with 
portal hypertension, as an alternative to upper GI endoscopy. 
The rules say that erosive esophagitis and Barretts esophagus may be viable clinical indications in the 
future, but further peer-reviewed literature is being sought before this additional coverage might become 
available. 
You can find this information in the Local Coverage Determination (LCD): Wireless Capsule Endoscopy 
(L35089). 
 
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 MRgFUS unilateral thalamotomy is considered medically reasonable and necessary in 
patients who have essential tremor (ET) and all of the following: 
 
    Medication refractory ET (defined as refractory to at least 2 trials of medical therapy, including at least 1 
first-line agent) 
    Moderate to severe postural or intention tremor of the dominant hand (defined by a score of =2 on the 
Clinical Rating Scale for Tremor (CRST)) 
    Disabling ET (defined by a score of =2 on any of the 8 items in the disability subsection of the CRST) 
    Has failed deep brain stimulation or is not able to tolerate the procedure due to other medical problems 
 
You can find this information in the Local Coverage Determination (LCD) Magnetic Resonance Image Guided 
High Intensity Focused Ultrasound (MRgFUS) for Essential Tremor L37761. 
 
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 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 a $45 copayment for each Medicare-covered specialist visit. You can find 
this information on page 88 of the Plan's 2022 Evidence of Coverage (EOC).  
 
The Plan contract also says that enrollees must pay 20% coinsurance of the allowed amount for Part B-covered 
drugs. You can find this information on page 80 of the Plan's 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 a second diagnostic facet procedure is considered medically necessary to confirm validity 
of the initial diagnostic facet procedure when administered at the same level. The second diagnostic procedure 
may only be performed a minimum of 2 weeks after the initial diagnostic procedure. Clinical circumstances 
that necessitate an exception to the two-week duration may be considered on an individual basis and must be 
clearly documented in the medical record. 
 
A second confirmatory diagnostic facet joint procedure is considered medically reasonable and necessary in 
patients who meet ALL the following criteria: 
1. The patient meets the criteria for the first diagnostic procedure; AND 
2. After the first diagnostic facet joint procedure, there must be a consistent positive response of at least 
80% relief of primary (index) pain (with the duration of relief being consistent with the agent used) 
 
You can find this rule in the Local Coverage Determination (LCD) for Facet Joint Interventions for Pain 
Management, L35936. 
 
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 this policy section describes coverage of NGS CGP diagnostic testing for patients with 
advanced cancer as allowable by a Medicare Administrative Contractor (MAC) under the National Coverage 
Determination (NCD) 90.2 (1). The policy scope is specific to solid tumors and exclusive of hematologic 
malignancies (the subject of separate LCD L37606), circulating tumor DNA testing (ctDNA), and other cancer-
related uses of NGS, such as germline testing. 
 
CGP is a NGS approach that uses a single assay to assess hundreds of genes including relevant cancer 
biomarkers, with solid evidentiary support for clinical utility in guidelines and clinical trials. CGP assays 
include not only individual genetic variants (single nucleotide variants (SNVs), insertions/deletions (INDELs), 
copy number alterations (CNAs), structural variants (SVs), and splice-site variants), but also patterns of 
mutations such as DNA mismatch repair deficiency (dMMR), microsatellite instability (MSI), and total 
mutational burden (TMB). CGP testing may also include RNA sequencing to detect structural rearrangements, 
such as fusions/translocations and functional splicing mutations. 
 
CGP NGS testing for patients with advanced cancer is reasonable and necessary only when performed in a 
CLIA-certified laboratory, when ordered by a treating physician, and when the patient has: 
 
    either recurrent, relapsed, refractory, metastatic, or advanced stages III or IV cancer; and 
    not been previously tested with a CGP for the same cancer genetic content; and 
    decided to seek further cancer treatment (e.g., therapeutic chemotherapy) 
 
Additionally, the test performed must be able to detect at least the minimum genes and genomic positions 
required for the identification of clinically supported, FDA-approved therapies. The genes and genomic 
positions required are listed in Category 1 or 2A of the most current version of the National Comprehensive 
Cancer Network (NCCN) Biomarkers Compendium (2). Testing assays must be FDA approved/cleared, or if a 
laboratory developed test (LDT), have a published, peer-reviewed study supporting analytic validity, or 
certification by a third-party consistent with the New York State Department of Healths Clinical Laboratory 
Evaluation Program (CLEP) review standards. 
 You can find this information in the Local Coverage Determination (LCD) Genomic Sequence Analysis Panels 
in the Treatment of Solid Organ Neoplasms L37810. 
 
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 it has not been established that a water circulating heat pad with pump (E0217) is 
reasonable and necessary compared to a standard electric heating pad (E0210); therefore, if code E0217 is 
provided it will be denied as not reasonable and necessary. You can find this rule at Centers for Medicare and 
Medicaid Services, Local Coverage Determination L33784 entitled "Heating Pads and Heat Lamps." 
 
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 abdominal lipectomy/panniculectomy will be considered medically necessary when the 
pannus or panniculus hangs below the level of the pubis, and the medical records document that the panniculus 
causes chronic intertrigo (dermatitis occurring on opposed surfaces of the skin, skin irritation, infection or 
chafing that consistently recurs or remains refractory to appropriate medical therapy (e.g. topical antifungals, 
corticosteroids, antibiotics) over a period of 3 months. 
 
The rules say that abdominal lipectomy/panniculectomy will be considered medically necessary when surgery 
is performed to alleviate such complicating factors as inability to walk normally due to pannus size, chronic 
pain, ulceration created by the abdominal skin fold, or intertrigal dermatitis, such surgery is considered 
reconstructive. Preoperative photographs may be required to support justification and should be supplied upon 
request. 
 
You can find this information in the Local Coverage Determination (LCD): Cosmetic and Reconstructive 
Surgery (L39051). 
 
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 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 for home health (HH) prospective payment system (PPS) periods of care, the distinct 5-
position, alphanumeric home health Health Insurance Prospective Payment System (HIPPS) codes are created 
as follows: 
 
1. The first position represents a combination of the referral source (community or institutional) and the period 
timing (early or late). 
2. The second and third positions represent the clinical and functional domains of the home health resource 
group (HHRG) coding system. 
3. The fourth position represents the co-morbidity category that applies to the patient. 
4. The fifth position is a placeholder for future use, required only because the field used to report HIPPS codes 
requires five positions. 
 
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 10, Section 10.1.9. 
 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 test panel is a single test with multiple components and is characterized by a single unit of 
service (UOS =1). A panel cannot be unbundled and billed as individual components regardless of the fact that 
the test reports multiple individual pathogens and/or targets. You can find this rule in the Local Coverage 
Article for the Billing and Coding of Molecular Diagnostics (MolDX): Molecular Syndromic Panels for 
Infectious Disease Pathogen Identification Testing, A58710. 
 
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 Medicare pays for ambulance services that meet certain requirements. One requirement is 
that the vehicle used as an ambulance must be equipped with emergency warning lights and sirens, 
communications equipment, a stretcher, linens, emergency medical supplies, oxygen equipment and other life-
saving equipment. Another requirement is that the vehicle used as an ambulance must be staffed with two 
people, one of whom is certified as an emergency medical technician. Medicare will not pay for transport by 
wheelchair vans because wheelchair vans are vehicles that do not meet these requirements. You can find this 
rule at 42 CFR Sections 410.41(a) and (b). 
 
The rules say that certain conditions have both an underlying etiology and multiple body system manifestations 
due to the underlying etiology. For such conditions, the international classification of diseases, tenth edition, 
clinical modification (ICD-10-CM) has a coding convention that requires the underlying condition be 
sequenced first, if applicable, followed by the manifestation. In most cases the manifestation codes will have in 
the code title, in diseases classified elsewhere. Codes with this title are a component of the etiology/ 
manifestation convention. The code title indicates that it is a manifestation code. In diseases classified 
elsewhere codes are never permitted to be used as first listed or principal diagnosis codes. There are 
manifestation codes that do not have in diseases classified elsewhere in the title. For such codes, there is a 
use additional code note at the etiology code and a code first note at the manifestation code, and the rules 
for sequencing apply. You can find this rule in the 2023 ICD-10-CM Diagnosis Codebook, Section I.A(13).  
 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 type 1 Excludes note is a pure excludes note. It means NOT CODED HERE! An 
Excludes1 note indicates that the code excluded should never be used at the same time as the code above the 
Excludes1 note. An Excludes1 is used when two conditions cannot occur together, such as a congenital form 
versus an acquired form of the same condition. You can find this rule in the 2022 ICD-10-CM Diagnosis 
Codebook, Section I.A(12). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare will not pay for dental services. Dental services are items and services involving 
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare 
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, 
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this 
rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes the 
prophylaxis - adult but is limited to two procedures per plan year. You can find this information in Chapter 4 
on page 4-61 of the Plan's 2022 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 the patients medical records must establish medical necessity for a hospital bed due to one 
of the following reasons: 
 
1. The patients condition requires positioning of the body; e.g., to alleviate pain, promote good body 
alignment, prevent contractures, avoid respiratory infections, in ways not feasible in an ordinary bed; or  
 
2. The patients condition requires special attachments that cannot be fixed and used on an ordinary bed.  
You can find this rule in the Centers for Medicare and Medicaid Services (CMS), Internet-Only Manual, 
Publication 100-03, Medicare National Coverage Determinations Manual, Section 280.7(A). 
 
In order to qualify for a semi-electric hospital bed, the patients condition must require frequent change in body 
position and/or there may be an immediate need for a change in body position (i.e., no delay can be tolerated) 
and the patient can operate the controls and cause the adjustments. Exceptions may be made to this last 
requirement in cases of spinal cord injury and brain damaged patients. 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 280.7(D). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.