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 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 
intraoral - complete series of radiographic images (D0210) but is limited to 1 procedure code every 5 years. 
You can find this information on page 76 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 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 an annual $1,500 dental benefit maximum allowance. You can find 
this information on pages 92-95 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 a health plan must disclose to its enrollees in clear, accurate terms all cost sharing information 
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and 
(b). 
 
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say 
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to 
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2.  
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that enrollees must pay 20% coinsurance for an out-of-network prosthetics provider. You can find 
this information on page 86 of the Plan's 2022 Evidence of Coverage (EOC).  
 
The Plan contract also says that enrollees must pay 20% coinsurance for an out-of-network prosthetics 
provider. You can find this information on page 75 of the Plan's 2023 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 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) L36807 and the related Local Coverage Article: Billing and Coding: MolDX: 
Molecular Diagnostic Tests (MDT) A57772.  
 
The rules say that the Correct Coding Initiative was developed to promote correct coding and to control 
improper coding leading to inappropriate payment in Part B claims. The Coding Policy Manual also explains 
what is referred to as Column One/Column Two Correct Coding and Mutually Exclusive Edits. These are code 
pairs that should not be reported together. Medicare Administrative Contractors (MACs) subject all line items 
for the same beneficiary, same National Provider Identifier (NPI), and same date of service to National Correct 
Coding Initiative (NCCI) edits. The National Correct Coding Initiative (NCCI) File Formats continue to 
include a Correct Coding Modifier Indicator (CCMI) for the Column One / Column Two Correct Coding edit 
file. This indicator determines whether an NCCI Procedure to Procedure (PTP)-associated modifier causes the 
code pair to bypass the edit. You can find this rule in the Centers for Medicare and Medicaid Services, Internet 
Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 23, Section 20.9. 
 
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 if a laboratory assays 2 or more genes in a patient in parallel, then those 2 or more genes will 
be considered part of the same panel. A panel constitutes a single procedural service, so 1 HCPCS codes must 
be submitted for the panel. If the laboratory assays genes in serial, then the laboratory must submit claims for 
genes individually. The order by the treating clinician must reflect whether the treating clinician is ordering a 
panel or single genes, and additionally, the patients medical record must reflect that the service billed was 
reasonable and necessary. You can find this information in the Local Coverage Article Billing and Coding: 
MolDX: Testing of Multiple Genes, A57880. 
 
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 PVA (percutaneous vertebroplasty (PVP) or kyphoplasty (PKP)) is covered in patients with 
BOTH the following: 
 
    Inclusion criteria (ALL are required): 
        Acute (< 6 weeks) or subacute (6-12 weeks) osteoporotic VCF (T1  L5), based on symptom onset, and 
documented by advanced imaging (bone marrow edema on MRI or bone-scan/SPECT/CT uptake) (1-
3,10,25,27) 
        Symptomatic (ONE): 
            Hospitalized with severe pain (Numeric Rating Scale (NRS) or Visual Analog Scale (VAS) pain score = 
8) (4-7) 
            Non-hospitalized with moderate to severe pain (NRS or VAS =5) despite optimal non-surgical 
management (NSM) (10) (ONE): 
                Worsening pain 
                Stable to improved pain (but NRS or VAS still =5) (with = 2 of the following): 
                    Progression of vertebral body height loss 
                    > 25% vertebral body height reduction 
                    Kyphotic deformity 
                    Severe impact of VCF on daily functioning (Roland Morris Disability Questionnaire (RDQ) >17 
 
You can find this information in the Local Coverage Determination (LCD) Percutaneous Vertebral 
Augmentation (PVA) for Osteoporotic Vertebral Compression Fracture (VCF) L33569. 
 
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 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 the know error DNA Specimen Provenance Assay is a forensic assay to confirm that a 
surgical specimen belongs to the patient evaluated for treatment. Although MolDX agrees the healthcare 
community should define and follow strict procedures regarding patient and patient specimen identification and 
handling, tests performed to measure the quality of a process do not provide information to diagnose or treat a 
patient illness or injury as defined in the Medicare benefit category. Therefore, the know error DNA 
Specimen Provenance Assay is a statutorily excluded test. You can find this rule in the Local Coverage Article 
for the Billing and Coding of Molecular Diagnostics (MolDX): know error, A55172. 
 
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 there are certain diagnosis codes which support the medical necessity of code 83036. Any 
codes which are not listed are considered not medically necessary for code 83036. You can find this 
information in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-03, 
National Coverage Determinations (NCD) Manual: Glycated Hemoglobin/Glycated Protein (190.21) Coding 
Policy Manual and Change Report (ICD-10-CM). 
 
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 plans may choose the networks of providers available to enrollees and may require enrollees 
to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in 
the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, Medicare 
Managed Care Manual, Chapter 1, Section 20.2. 
 
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, 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 pages 28-30 and 44 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 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) L36256 and the related Local Coverage Article: Billing and Coding: MolDX: 
Molecular Diagnostic Tests (MDT) A57527.  
 
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 a list of 
covered dental services with frequency and limitations of each service and what you pay for each service. 
Dental codes D5630 and D5640 are covered for one procedure code per calendar year with a 50% coinsurance. 
Dental code D5720 is covered for one procedure code per calendar year with a 50% coinsurance. You can find 
this information in Chapter 4 on page 79 of the Plans 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 state that Group 2 power operated vehicles (POVs) (K0806, K0807, K0808) have added capabilities 
that are not needed for use in the home. Therefore, if a Group 2 POV is provided it will be denied as not 
reasonable and necessary. You can find this information in Local Coverage Determination (LCD): Power 
Mobility Devices (L33789). 
 
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 Detailed Written Order (DWO) (if applicable) must be received by the supplier before a 
claim is submitted. If the supplier bills for an item addressed in this policy without first receiving a completed 
DWO, the claim shall be denied as not reasonable and necessary. You can find this information in the Local 
Coverage Determination (LCD) for Wheelchair Options / Accessories (L33792). 
 
The rules also say that prior to or at the time of delivery of a power operated vehicle (POV) or power 
wheelchair (PWC), the supplier or practitioner must perform an on-site evaluation of the beneficiarys home to 
verify that the beneficiary can adequately maneuver the device that is provided considering physical layout, 
doorway width, doorway thresholds, and surfaces. There must be a written report of this evaluation available 
on request. You can find this information in the Local Coverage Determination (LCD) for Power Mobility 
Devices (L33789). 
 
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. 
 
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 Pap tests and pelvic exams are covered once every 24 months. You can find this 
information on page 50 of the Plan's 2023 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that repeat thermal facet joint RFA at the same anatomic site is considered medically reasonable 
and necessary provided the patient had a minimum of consistent 50% improvement in pain for at least six (6) 
months or at least 50% consistent improvement in the ability to perform previously painful movements and 
ADLs as compared to baseline measurement using the same scale. You can find this rule at Local Coverage 
Determination (LCD) L34892: Facet Joint Interventions for Pain Management (eff. 4/25/21). 
 
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 Percepta BGC is covered only when the following clinical conditions are met: 
 
1. Current or former smokers age 21 or greater, and 
2. Physician-assessed low or intermediate pretest risk of malignancy based upon clinical characteristic 
stratification, and 
3. Bronchoscopy is non-diagnostic (actionable benign or malignant diagnosis cannot be reached), and 
4. Percepta BGC results will be utilized to determine whether CT surveillance is appropriate in lieu of further 
invasive biopsies or surgical procedures, and 
5. Test is ordered by physician certified in Percepta Certification and Training Registry (CTR), and 
6. Patient is monitored for malignancy (suggested monitoring includes serial CT scans at 3 to 6, 9 to 12, and 18 
to 24 months, using thin sections and non-contrast, low-dose techniques), and 
7. Physician will report outcomes in all risk groups including those monitored initially and those who undergo 
immediate intervention, and 
8. Clinical management is consistent with the post-test diagnostic strategy described above in 80% or more of 
tested patients. 
 
You can find this rule in the Local Coverage Determination (LCD) - MolDX: Percepta Bronchial Genomic 
Classifier (L36886). 
 
The rules say that the Percepta BGC test should not be ordered if a physician does not intend to act upon the 
test result. You can find this rule in the Local Coverage Determination (LCD) - MolDX: Percepta Bronchial 
Genomic Classifier (L36886). 
 
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.