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 non-coverage has been reaffirmed by Medicare for codes 0012M and 0013M for 
CxBladder. You can find this rule at Centers for Medicare and Medicaid Services, Local Coverage 
Determination L35396 entitled Biomarkers for Oncology. 
 
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 for outpatient claims, providers report the full diagnosis code for the diagnosis shown to be 
chiefly responsible for the outpatient services. You can find this rule at Centers for Medicare and Medicaid 
Services, Internet-Only Publication 100-04, Medicare Claims Processing Manual Chapter 23, Section 10.3. 
 
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 that International Classification of Diseases (ICD-10) codes with an Excludes1 note 
indicate it is a pure excludes note. 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 at 
Centers for Medicare and Medicaid Services, ICD-10-CM Official Guidelines for Coding and Reporting, 
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 state that telehealth services should be billed using either Place of Service (POS) code 02 (telehealth 
provided other than in a patient's home), or 10 (telehealth provided in a patient's home).  You can find this rule 
at Centers for Medicare and Medicaid Services, MLN Matters Article entitled New/Modifications to the Place 
of Service (POS) Codes for Telehealth, MM12427, Change Request 12427. 
 
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 in order for a Next Generation Sequencing lab test to be considered for coverage, the test 
must be approved by the Food and Drug Administration (FDA). You can find this rule at Centers for Medicare 
and Medicaid Services, National Coverage Determination 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 state that all End Stage Renal Disease (ESRD) claims with dates of service on or after July 1, 2010, 
must indicate the applicable Kt/V reading for the dialysis patient. The reading result and the date of the reading 
must be reported on the claim using Value Code D5. This must be accompanied by Occurrence Code 51 to 
indicate the date of the last Kt/V reading. 
 
Renal dialysis facilities are required to report hematocrit or hemoglobin levels for their Medicare patients 
receiving erythropoietin products. Hematocrit levels are reported in value code 49 and reflect the most recent 
reading taken before the start of the billing period. Hemoglobin readings before the start of the billing period 
are reported in value code 48. 
 
You can find this rule at Centers for Medicare and Medicaid Services, Internet-Only Publication 100-04, 
Medicare Claims Processing Manual Chapter 8, Sections 50.8 and 60.4.2. 
 
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 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 
requested item or service but is limited to one upper complete and/or one lower complete denture every five 
calendar years, including routine post-delivery care. You can find this information on pages 81 to 85 of the 
Plan's 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 the CLIA mandates that virtually all laboratories, including physician office laboratories 
(POLs), meet applicable Federal requirements and have a CLIA certificate in order to receive reimbursement 
from Federal programs. 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 16, Section 70.1. 
 
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 pharmacogenetics testing will be considered medically reasonable and necessary if: 
 
    The patient has a condition where clinical evaluation has determined the need for a medication that has a 
known gene-drug interaction(s) for which the test results would directly impact the drug management of the 
patients condition; AND 
 
    The test meets evidence standards for genetic testing as evaluated by a scientific, transparent, peer-reviewed 
process and determined to demonstrate actionability in clinical decision making by CPIC guideline level A or 
B1; or is listed in the FDA table of known gene-drug interactions where data support therapeutic 
recommendations or a potential impact on safety or response or the FDA label. 
 
In addition, pharmacogenetic testing is not considered reasonable and medically necessary when either 
analytical validity, clinical validity, or clinical utility has not been established. 
 
You can find this rule at Centers for Medicare and Medicaid Services, Local Coverage Determination L39063 
entitled Pharmacogenomics Testing. 
 
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 pharmacogenetics testing will be considered medically reasonable and necessary if: 
 
1. The patient has a condition where clinical evaluation has determined the need for a medication that has a 
known gene-drug interaction(s) for which the test results would directly impact the drug management of the 
patients condition; AND 
2. The test meets evidence standards for genetic testing as evaluated by a scientific, transparent, peer-reviewed 
process and determined to demonstrate actionability in clinical decision making by CPIC guideline level A or 
B; or is listed in the FDA table of known gene-drug interactions where data support therapeutic 
recommendations or a potential impact on safety or response or the FDA label 
 
You can find this rule in the Local Coverage Determination (LCD) - Pharmacogenomics Testing (L39073) - 
Effective December 12, 2021. 
 
The rules say that genetic testing where either analytical validity, clinical validity, or clinical utility has not 
been established is not considered medically reasonable or necessary. You can find this rule in the Local 
Coverage Determination (LCD) - Pharmacogenomics Testing (L39073) - Effective December 12, 2021. 
 
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 pharmacogenetics testing will be considered medically reasonable and necessary if: 
The patient has a condition where clinical evaluation has determined the need for a medication that has a 
known gene-drug interaction(s) for which the test results would directly impact the drug management of the 
patients condition; AND 
 
The test meets evidence standards for genetic testing as evaluated by a scientific, transparent, peer-reviewed 
process and determined to demonstrate actionability in clinical decision making by CPIC guideline level A or 
B1; or is listed in the FDA table of known gene-drug interactions where data support therapeutic 
recommendations or a potential impact on safety or response or the FDA label 
 
You can find this rule at Centers for Medicare and Medicaid Services, Local Coverage Determination L39073 
entitled Pharmacogenomics testing. 
 
The rules say that genetic testing for hereditary cardiovascular disease will be considered medically reasonable 
and necessary if: 
 
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 
 
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: 
 Disease severity of sudden death, possible death or major morbidity, modest morbidity 
 Substantial or moderate evidence of a greater than 40 percent likelihood of disease 
 Substantial or moderate evidence of a highly effective or moderately effective intervention The nature of intervention is either low risk/medically acceptable/low intensity intervention or 
moderately acceptable/risk/intensive interventions, AND 
 
Clinical validity and qualitative descriptors from Moderate, Strong & Definitive with contradictory evidence 
NOT being reported as disputed or refuted. 
 
You can find this rule at Centers for Medicare and Medicaid Services Local Coverage Determination L39084 
entitled Genetic Testing for Cardiovascular Disease. 
 
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 pharmacogenetics testing will be considered medically reasonable and necessary if: 
 
    The patient has a condition where clinical evaluation has determined the need for a medication that has a 
known gene-drug interaction(s) for which the test results would directly impact the drug management of the 
patients condition; AND 
 
    The test meets evidence standards for genetic testing as evaluated by a scientific, transparent, peer-reviewed 
process and determined to demonstrate actionability in clinical decision making by CPIC guideline level A or 
B1; or is listed in the FDA table of known gene-drug interactions where data support therapeutic 
recommendations or a potential impact on safety or response or the FDA label;  
 
The following is considered not medically reasonable and necessary: 
 
    Genetic testing where either analytical validity, clinical validity, or clinical utility has not been established. 
    Germline testing may be performed once in a lifetime per beneficiary. 
 
You can find this rule at Centers for Medicare and Medicaid Services, Local Coverage Determination L39073 
entitled Pharmacogenomics Testing. 
 
The rules say that genetic testing for hereditary cardiovascular disease will be considered medically reasonable 
and necessary if: 
 
    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     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: 
        Disease severity of sudden death, possible death or major morbidity, modest morbidity 
        Substantial or moderate evidence of a >40% likelihood of disease 
        Substantial or moderate evidence of a highly effective or moderately effective intervention 
        The nature of intervention is either low risk/medically acceptable/low intensity intervention or moderately 
acceptable/risk/intensive interventions, 
        AND 
    Clinical validity and qualitative descriptors from Moderate, Strong & Definitive with contradictory evidence 
NOT being reported as disputed or refuted. 
 
You can find this rule at Centers for Medicare and Medicaid Services, Local Coverage Determination l39084 
entitled "Genetic Testing for Cardiovascular Disease. 
 
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. This benefit does not include 
the inhalation of nitrous oxide. You can find this information on pages 58-60 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 a fluid, pneumatic, or electronic/microprocessor knee (L5610, L5613, L5614, L5722, L5724, 
L5726, L5728, L5780, L5814, L5822, L5824, L5826, L5828, L5830, L5840, L5848, L5856, L5857, L5858) is 
covered for beneficiaries whose functional level is 3 or above. 
 
Coverage is extended only if there is sufficient clinical documentation of functional need for the technologic or 
design feature of a given type of knee. This information must be retained in the treating practitioner's or 
prosthetist's files. 
 
Clinical assessments of beneficiary rehabilitation potential must be based on the following classification levels: 
 
Level 0: Does not have the ability or potential to ambulate or transfer safely with or without assistance and a 
prosthesis does not enhance their quality of life or mobility. 
 
Level 1: Has the ability or potential to use a prosthesis for transfers or ambulation on level surfaces at fixed 
cadence. Typical of the limited and unlimited household ambulator. 
 
Level 2: Has the ability or potential for ambulation with the ability to traverse low level environmental barriers 
such as curbs, stairs or uneven surfaces. Typical of the limited community ambulator. 
 
Level 3: Has the ability or potential for ambulation with variable cadence. Typical of the community ambulator 
who has the ability to traverse most environmental barriers and may have vocational, therapeutic, or exercise 
activity that demands prosthetic utilization beyond simple locomotion. 
 
Level 4: Has the ability or potential for prosthetic ambulation that exceeds basic ambulation skills, exhibiting 
high impact, stress, or energy levels. Typical of the prosthetic demands of the child, active adult, or athlete. 
 
The records must document the beneficiary's current functional capabilities and his/her expected functional 
potential, including an explanation for the difference, if that is the case. It is recognized, within the functional 
classification hierarchy, that bilateral amputees often cannot be strictly bound by functional level 
classifications. 
 
You can find this information in Local Coverage Determination (LCD): Lower Limb Prostheses (L33787). 
 
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. This benefit includes specific 
dental procedures included in a dental benefits chart. Core buildup is not listed as a covered dental benefit. You 
can find this information on pages 80-82 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 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 $150 copayment for Medicare-covered diagnostic radiology services. 
You can find this information on pages 54 to 55 of the Plan's 2022 Evidence of Coverage (EOC).